Every fall, from October 15 through December 7, Medicare opens its annual enrollment window — the one time each year most beneficiaries can switch plans, change drug coverage, or move between Original Medicare and Medicare Advantage. For families thinking about nursing home care, this window is easy to overlook: the person you are planning for may be healthy today. But the plan choices made this December determine which skilled nursing facilities are in-network next year, what the cost-sharing looks like, and whether the drug coverage still fits.
This checklist turns Open Enrollment into a long-term care planning exercise. Work through it once a year — ideally in October, while there is still time to compare — and you will enter January with no surprises about the coverage that matters most when care becomes urgent.
Why Open Enrollment Matters for Long-Term Care Planning
Medicare plans change every year, and so do care needs. A plan that was perfect last year may have dropped the nursing facility near your home from its network, raised its skilled nursing copays, or moved a critical medication to a higher cost tier. Meanwhile, your loved one’s health may have shifted in ways that make next year’s likely needs different — a recent fall, a new diagnosis, a hospital stay that put skilled nursing on the radar.
The connection to long-term care is indirect but real. Medicare does not pay for long-term custodial nursing home care — that is Medicaid’s territory, or private funds — but Medicare does pay for the short-term skilled nursing stays that so often precede a long-term placement. Which facilities are covered, what you pay per day, and how authorizations work are all plan features you lock in during this window. Families who review them now avoid discovering the gaps from a hospital discharge lounge in March. If the cost side of this planning is new to you, start with our guide to nursing home costs for the full financial picture.
The Checklist: Ten Things to Review Before December 7
- Read the Annual Notice of Change (ANOC). Every plan mails this in September. It lists exactly what changes on January 1 — premiums, copays, networks, drug tiers. Read the skilled nursing facility section line by line; it is short and it is the part that matters most here.
- Confirm the plan type still fits. Original Medicare plus Medigap offers nationwide flexibility and predictable cost-sharing; Medicare Advantage often offers lower premiums with networks and authorization rules. Neither is universally better for care planning — the right answer depends on where your loved one lives and which facilities you would actually use.
- Check the SNF network. For Medicare Advantage members: is the skilled nursing facility near home still in-network? Networks change annually. Call the plan or use the online directory — do not assume last year’s list still holds.
- Review SNF cost-sharing. What is the copay per day, and from which day does it start? Some Advantage plans charge from day one; Original Medicare charges nothing for days 1–20. Multiply the daily figure by a plausible stay length so the number is concrete.
- Check prior authorization rules. Does the plan require approval before a SNF admission? Who requests it, and how fast is the turnaround? In a post-hospital scramble, a 72-hour authorization delay is a real problem — know the process now.
- Review the drug formulary. Pull the current medication list and check every drug’s tier and any new prior-authorization or step-therapy requirements. One moved medication can cost more per year than the plan’s entire premium difference.
- Confirm the pharmacy network. If your loved one uses a specific pharmacy — especially a long-term care pharmacy that serves nursing facilities — verify it is still preferred next year.
- Check extra benefits honestly. Dental, vision, hearing, and fitness perks are nice, but weigh them against SNF cost-sharing and network breadth. A plan with generous gym benefits and a narrow SNF network is a bad trade for a family planning around care needs.
- Verify the primary care relationship. Referral requirements and PCP networks affect how quickly a hospital-to-SNF path can be arranged. If the trusted doctor is leaving the network, that alone can justify a switch.
- Put the decision in writing. Note what you chose and why, and where the key documents live (ANOC, Evidence of Coverage, insurance cards). Future-you, in a stressful moment, will be grateful.
How to Read Your Annual Notice of Change
The ANOC looks intimidating but rewards ten focused minutes. Skip to the summary of changes table — it compares this year and next year side by side for premiums, deductibles, and copays. Then find the section on skilled nursing facility care specifically: note the per-day copay, the day it begins, and any annual day limits. Finally, scan the drug section for formulary changes affecting current medications. Anything you do not understand is a question for the plan’s member services line or a SHIP counselor (more on them below) — not a reason to ignore the document. Plans are required to send the ANOC by September 30; if it never arrived, request one immediately, because the December 7 deadline does not move for missing mail.
Checking Whether Your Plan Still Covers the Facilities You’d Use
This is the step families skip and later regret. Make a short list of the skilled nursing facilities you would actually consider — near home, near family, or near the hospital your loved one uses — and verify each one against next year’s network. For Original Medicare, any Medicare-certified facility qualifies; for Medicare Advantage, only in-network facilities get the favorable rates, and out-of-network SNF care can be dramatically more expensive or require special approval.
Verification beats assumption: plan directories update, facilities change ownership, and contracts lapse. Call the facility’s admissions office and ask directly, “Will you be in-network for [plan name] in [next year]?” Then confirm with the plan. Two confirmations take twenty minutes and prevent the worst kind of surprise — learning at discharge that the chosen facility is out of network.
Prescription Coverage: Small Changes, Big Bills
Drug coverage deserves its own careful pass because it changes silently and costs loudly. Each year, plans adjust which tier each drug sits on, which drugs require prior authorization, and which pharmacies are preferred. For someone taking several maintenance medications — common at the ages when nursing home planning begins — a single drug moving from a preferred tier to a specialty tier can add thousands per year.
The practical method: list every current prescription with dose and frequency, then run the list through the plan’s formulary lookup for next year (and through Medicare’s Plan Compare tool, which prices total drug costs across plans). Pay special attention to drugs commonly used in long-term care settings — if a nursing home stay becomes likely, the facility’s pharmacy arrangements and the plan’s long-term care pharmacy network both matter.
Medigap vs. Medicare Advantage: A Care-Planning View
Families often ask which coverage type is “better” for nursing home planning. The honest answer is that they optimize for different risks. Original Medicare with a Medigap policy typically offers the broadest facility choice — any Medicare-certified SNF nationwide — with predictable cost-sharing and no network to check. That flexibility is valuable when care needs are uncertain or when family members live in different states (a theme our long-distance caregiving guide explores in depth).
Medicare Advantage typically offers lower monthly premiums and bundled extras, but ties you to networks and authorization processes that require active management. For a healthy person with a stable local network, that trade can be excellent. For a family already watching a parent decline, the network constraints deserve hard scrutiny during Open Enrollment — because the year you need the flexibility is the year you cannot buy it.
One caution in both directions: switching from Medicare Advantage back to Original Medicare later can trigger Medigap underwriting in many states, meaning a Medigap policy may be denied or priced on health history. Understand the reversibility of your choice before you make it — a SHIP counselor can explain your state’s rules.
Cost Questions to Answer Before December 7
Turn the review into numbers. For each plan under consideration, answer: What is the total annual premium? What would a 20-day SNF stay cost out of pocket? A 60-day stay? What is the maximum out-of-pocket limit (Medicare Advantage plans have one; Original Medicare does not, which is what Medigap addresses)? What will next year’s prescriptions cost under the new formulary? Add the premium to the plausible care scenarios — not just the best case. The cheapest premium is rarely the cheapest plan for a family with real care needs on the horizon.
Where to Verify Everything Before You Decide
You do not have to do this alone, and you should not rely on plan marketing alone. Three authoritative resources:
- Medicare Plan Compare at medicare.gov — the official comparison tool. Enter drugs, pharmacies, and doctors to see true total costs across plans.
- SHIP (State Health Insurance Assistance Program) — free, unbiased, in-person or phone counseling in every state. Find yours through eldercare.acl.gov or by calling the Eldercare Locator. SHIP counselors are the single most underused resource in Medicare planning.
- 1-800-MEDICARE — for direct questions about coverage rules, available 24/7. Useful for confirming how a specific benefit works before you commit.
Be wary of unsolicited calls and ads during Open Enrollment season — it is also peak season for misleading Medicare marketing. Legitimate help never pressures you to decide on the spot, and SHIP counseling is always free. If someone asks for your Medicare number to “check your eligibility,” hang up; no legitimate enrollment requires that over an unsolicited call.
After You Enroll: What to Confirm in January
The work is not quite done on December 7. In January, confirm the new plan’s ID cards arrived, verify the PCP and pharmacy designations took effect, re-check that the preferred SNF list is what you expected, and re-run the drug list against the live formulary (early-year corrections are common). Save the new Evidence of Coverage where the family can find it, and update the one-page summary you wrote in the fall. If something is wrong, the Medicare Advantage Open Enrollment Period (January 1–March 31) allows one switch — a safety net, not a plan, but good to know it exists.
Families who also want an advocate inside the system should know about the Long-Term Care Ombudsman Program — free advocates for nursing home residents in every state — and if memory care is on the horizon, our introduction to what memory care is pairs naturally with this planning. Open Enrollment comes once a year; the decisions compound for years. Spend the October afternoon now, and January-you will be glad you did.
General information only — not medical or legal advice. Always verify with licensed professionals.
