With more than 60 million enrollees, there will never be a shortage of people who have problems with Medicare. I know, because I spend hours every week fielding their questions! I also work closely with nonprofit Medicare counseling and advocacy groups that handle oodles of Medicare questions and issues.
The Medicare Rights Center annually reviews incoming public inquiries. The most frequent questions are about what Medicare covers, access to prescription drugs, and Medicare’s low-income payment support programs.
The State Health Insurance Assistance Program (SHIP) offers free Medicare counseling through state programs across the country. Chris Reeg oversees the SHIP in Ohio, called the Ohio Senior Health Insurance Information Program. Consumers have gained a greater understanding of Medicare over the years, she notes, but the program has become increasingly complicated. “The Medicare you knew last year is not the same Medicare you see this year,” Reeg says.
In this column, I’ll touch on a handful of the most common Medicare issues, according to my readers as well as experts at the Medicare Rights Center and SHIP. While each issue is unique to the person experiencing it, one thing they all have in common: they can be difficult and time-consuming to fix. So a theme you’ll pick up on below is the importance of being proactive about understanding your coverage before seeking care so you can hopefully avoid encountering these issues in the first place.
Most major health care decisions involve your doctors, but when it comes to Medicare coverage, you should not take what your doctor’s office says as the final or official word. I don’t know about you, but I go to my doctors because of their medical skills, not their insurance knowledge. Confirm what you’re told with either Medicare or your health plan, if you’re enrolled in a Medicare Advantage or Medigap supplemental plan. And, to repeat, do this before receiving medical care.
Many Medicare enrollees have other insurance as well, such as a group plan through their former employer or even a health component of their auto insurance. Figuring out how these benefits are coordinated can be the Rubik’s Cube of health care, Reeg says, so it’s vital to understand ahead of time which insurance is primary, which pays secondary, and whether one type of insurance will cover you if another one will not.
If you are having problems affording your Medicare premiums and health care expenses, you should look into Medicare Savings Programs (MSPs) for lower-income enrollees. Another program known as Extra Help can help with drug expenses. If you need help understanding these programs and whether you’re eligible, call your health plan or get in touch with SHIP. Every state has a SHIP office and counselors who can provide free assistance with health insurance issues and questions.
Lastly, if you are denied coverage – for health procedures, medical equipment or, as often happens, prescription drugs – you do have options through the appeals process, which is explained here. Filing an appeal is admittedly a complex process, but reversals on appeal are not uncommon, so don’t give up if your claim is denied. And work with your doctor or other care provider on your appeal. A letter from your doctor explaining the need for your drug, procedure or other health care service can often boost your chances of a positive outcome.
Some Medicare issues are specific to the type of coverage you have, so below I’ve outlined some of the most common things that trip people up, depending on whether they have Original Medicare, a Medicare Advantage plan or Part D prescription drug coverage.
Original Medicare (Parts A and B)
Coverage. Medicare does not cover everything and usually has limits – in dollars, time or both – on what it does cover. Medicare does not cover long-term care, care outside the U.S., or basic dental, hearing and vision care. Medicare’s online tool of what it does cover can be helpful if you’re preparing to seek care or undergo a procedure.
Copays and Coinsurance. Part B covers expenses for doctors, outpatient care and durable medical equipment. But it only pays 80 percent of these covered expenses. If you receive a lot of medical care in a given year, your 20 percent of the charges can really add up, which is the main reason Medigap supplemental insurance is so popular for people who choose to stick with Original Medicare. Here is a summary of Part A and B costs.
Medicare Summary Notices (MSNs). These reports track your Medicare claims, including what providers charge, the portion of those charges allowed to be billed to you under Medicare rules, the share your insurance paid and the share you may owe. They also provide details on any claims that have been denied. With so much information packed into them, they can be tricky to understand. Your local SHIP office can help you make sense of your MSNs. You might also find this YouTube video helpful.
Medicare Advantage (MA) Plans
MA plans are chosen by more than a third of Medicare beneficiaries, up from virtually zero in 2006. They can package all your Medicare insurance needs into a single plan. They often cost less than Original Medicare with a Part D plan and a Medigap supplemental plan. And they may offer features you can’t get with Original Medicare, including health club memberships and coverage of dental, vision and hearing needs.
Provider Networks. Original Medicare provides coverage anywhere in the U.S. from any medical provider that accepts Medicare. MA plans, by contrast, work with a network of providers, and those providers are typically located in the area near your community. MA enrollees should know who is in their plan’s provider network and should ask their insurer what happens if they receive care from someone outside the plan network. Some plans offer out-of-network coverage but may charge higher fees. Others may not cover such services at all.
Part D Drug Plans (Stand Alone or as Part of Medicare Advantage)
Formularies. By now, I hope you know how your plan covers the drugs you’re taking and what they cost. If not, use Medicare’s Plan Finder to get these details. You can also ask your plan to point you to where you can find your formulary (i.e. the plan’s list of covered drugs) on your plan website or to mail a copy to you.
The “Donut Hole." All Part D plans must comply with Medicare’s complicated “donut hole” rules. If you don’t understand them and how they apply to you, call your insurer or SHIP, especially if you think you could fall into the donut hole in 2018 (i.e. you take many prescriptions and/or high-cost medications).
Drug Denials. Most drug plans use five different pricing tiers, ranging from generics to very expensive specialty medications. Medicare does not cover all drugs, and your plan’s formulary may not include all drugs that are eligible for Medicare coverage. Also, in rare cases, a plan’s formulary can change during a plan year, as can what it charges for drugs. Medicare provides extensive appeal rights to consumers who have received a denial for a drug their doctor prescribed, and insurers must respond to an appeal within a few days, or even within 24 hours in some cases for appeals involving critically needed drugs.
Plan Rules and Regulations. Most Part D plans have rules requiring you to get the plan’s approval before filling certain prescriptions, limiting the quantity of drug you can receive, and asking you to take a less-expensive drug if your doctor prescribes a more costly medication. You should understand these rules and your appeal rights ahead of time.
Journalist Phil Moeller is an expert on retirement and aging. He writes the “Ask Phil” column for the PBS NewsHour and is the author of “Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs” as well as the co-author of the updated edition of The New York Times bestseller “How to Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security.” You can follow him on Twitter (@PhilMoeller) or reach him via e-mail: AskPhilByUHC@gmail.com.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies. For Medicare Advantage and Prescription Drug Plans: A Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare.