3 Essential Steps Before Medicare’s Annual Enrollment and Critical Procedures Medicare Advantage May Deny in 2024

Medicare’s Annual Enrollment Period (AEP) offers beneficiaries the opportunity to review, adjust, or switch their Medicare coverage to ensure it meets their health and financial needs. However, navigating this enrollment period can feel overwhelming, especially with new changes to drug plans and evolving Medicare Advantage policies. This article breaks down three essential steps everyone should take before the AEP begins on October 15th. Additionally, we’ll explore five critical procedures that Medicare Advantage plans have denied coverage for in 2024—highlighting the importance of informed decision-making.

Step 1: Review the Annual Notice of Change (ANOC) and Evaluate Providers

Each year, Medicare Advantage and prescription drug plans send out an Annual Notice of Change (ANOC), detailing modifications to premiums, out-of-pocket costs, and coverage rules for the upcoming year. It’s crucial to carefully review this notice to avoid surprises in 2025.

“Understanding changes to your plan helps you avoid gaps in coverage and ensures your care providers and prescriptions remain in-network.”

Key actions to take:

• Verify plan availability: Ensure your current plan will continue in 2025 and check for any premium increases or changes to co-pays and deductibles.
• Evaluate providers: Confirm that your primary care doctor, specialists, hospitals, and durable medical equipment (DME) providers remain in-network.
• Review prescription coverage: Check the formulary list to ensure your medications are still covered and preferred pharmacies are included.

These proactive steps can prevent unexpected expenses and ensure you have uninterrupted access to the care and medications you need.

Step 2: Understand the 2025 Drug Plan Restructuring

Starting in 2025, Medicare’s drug coverage will follow a new three-phase structure: deductible, initial coverage, and catastrophic coverage. Understanding these phases helps beneficiaries plan for potential out-of-pocket costs more effectively.

“Knowing how drug plans are structured ensures you’re prepared for costs at different stages of the year.”

Here’s what to expect:

• Deductible phase: Beneficiaries must pay up to $590 out of pocket before the drug plan starts covering costs.
• Initial coverage phase: After meeting the deductible, the plan covers prescriptions until total drug spending reaches $2,000.
• Catastrophic coverage phase: Once spending exceeds $2,000, the plan provides 100% coverage for the remainder of the year.

This new structure aims to simplify drug coverage, but it’s important to budget for each phase to avoid financial surprises.

Step 3: Evaluate Health Conditions and Plan Switching Options

Certain health conditions or ongoing treatments can impact your eligibility for insurance plans. Medicare Advantage and traditional Medicare offer different levels of coverage, and it’s essential to align your plan with your healthcare needs.

“Plan switches often require underwriting, so understanding how your health conditions affect eligibility is essential.”

When considering plan changes:

• Disclose any ongoing treatments or surgeries to avoid denied coverage.
• Evaluate whether Medicare Advantage or a supplemental Medigap policy better suits your needs. Medigap policies offer more flexibility but may require medical underwriting during plan switches.
• Factor in budget and comfort level with premiums and out-of-pocket costs, especially if you’re considering switching from Medicare Advantage to traditional Medicare.

5 Critical Procedures Medicare Advantage Plans Denied in 2024

While Medicare Advantage plans offer attractive benefits, they have been criticized for denying coverage for essential medical procedures. Knowing what may be denied helps beneficiaries make informed decisions about their healthcare options.

Here are five key procedures that faced coverage denials in 2024:

1. Advanced imaging tests (MRIs and CT scans): Often denied due to pre-authorization requirements.
2. Physical therapy sessions: Some plans limited the number of covered sessions despite doctors’ recommendations.
3. Cancer treatments (radiation and chemotherapy): Delays and denials have been reported due to strict pre-approval processes.
4. Inpatient rehabilitation stays: Denied coverage forced patients to seek outpatient alternatives.
5. Cardiac procedures: Including heart stents, which some Medicare Advantage plans deemed unnecessary despite clinical recommendations.

“Pre-authorization delays and coverage denials can compromise timely care—something to consider when choosing between Medicare Advantage and traditional Medicare.”

Staying informed about these denials ensures beneficiaries are prepared to navigate the appeals process or consider switching to traditional Medicare if they require more comprehensive coverage.

Next Steps: Take Control Before the Medicare Annual Enrollment Period

Navigating the Medicare Annual Enrollment Period requires thoughtful planning to ensure your healthcare and financial needs are covered. Here are the key actions to take:

• Review the ANOC to stay updated on changes to your current plan.
• Confirm that your doctors, hospitals, and prescriptions remain covered under your plan for 2025.
• Prepare for the new drug plan structure by budgeting for the deductible, initial coverage, and catastrophic phases.
• Evaluate your health conditions and explore your plan-switching options with underwriting requirements in mind.
• Consider working with a Medicare advisor or independent broker to ensure you make the best choices for your healthcare needs.

Conclusion: Stay Informed for a Healthy and Happy Retirement

Medicare’s Annual Enrollment Period is a crucial time for beneficiaries to review their healthcare plans and make necessary adjustments. With the new changes in drug plan structures and increasing coverage denials from Medicare Advantage plans, it’s more important than ever to stay informed and proactive.

By following these three steps—reviewing your plan, understanding the new drug phases, and evaluating health-related plan options—you can make confident choices that ensure comprehensive and affordable healthcare throughout your retirement.