Medicare is complicated and it’s not always easy to know if a service or item you need is covered. Below are four main points, outlined in Medicare Rights Center’s and SMP’s July Medicare Minute article, to help troubleshoot any potential Medicare coverage problems.
Point 1: Learn Medicare coverage rules.
You do not need to know all of Medicare’s coverage rules, but before getting a service, check to make sure Medicare covers it and if there are any steps you must take to receive it. If Original Medicare or your Medicare Advantage Plan does not cover a service, it may be because you did not follow or meet coverage rules. For example, some Medicare Advantage Plans require a referral from a primary care physician before they will cover a visit to a specialist. In other cases, Medicare only covers certain preventive screenings if you meet the criteria. A service may also not be covered if it is an excluded service, such as cosmetic surgery.
To learn about Original Medicare’s coverage of a needed service, call 1-800-MEDICARE or visit Medicare.gov, read the relevant sections of your Medicare & You handbook, or speak with your provider. You can also visit our Medicare Basics section on our website. To learn about how your Medicare Advantage Plan covers a service, call your plan or read your plan’s handbook. You can visit our Medicare Advantage section and/or call your local Health Insurance Counseling and Advocacy Program (HICAP) to learn more about your Medicare coverage rules.
Point 2: Understand your Medicare notices.
The Medicare Summary Notice, or MSN, is a document sent to people with Original Medicare. It is a summary of health care services and items you have received. If you have a Medicare Advantage Plan or Part D plan, you receive an Explanation of Benefits, or EOB. An EOB is similarly a summary of services and items that you have received. MSNs are mailed quarterly, while EOBs are usually sent monthly, unless your plan was not billed for any services during that time. Both MSNs and EOBs show the amount that Medicare or your private plan was billed, the amount that they paid, and the amount that you are responsible for. Neither an MSN nor an EOB is a bill. If you disagree with a non-covered charge, you can decide to file an appeal.
If you have a Medicare Advantage Plan, you may receive a notice called the Integrated Denial Notice, or IDN. Your plan must send you an IDN if it denies your request for coverage or will be discontinuing or reducing your previously authorized treatment. The IDN will list what services are being denied or discontinued, as well as the Medicare coverage rules that support their decision. On the final pages of the IDN is information on your right to appeal the decision, the steps to appealing, and resources to call for assistance. Part D plans will send you a similar notice if denying prescription drug coverage. If you receive an IDN or denial notice, read it carefully to guide your appeal and to ensure that your appeal addresses the plan’s reason for denial.
If you are enrolled in a prescription drug plan through an employer, you should receive a notice from your employer or plan around September of each year, informing you if your drug coverage is creditable. Keep these notices of creditable coverage each year. If you decide to enroll in a Part D plan in the future, you may need these notices as proof that you had creditable coverage and should not have a Part D late enrollment.
Point 3: Know who to contact when issues arise.
There are a few different places you can contact, depending on your issues or question. Contact the Social Security Administration, or SSA, for Medicare Part A and B enrollment and premium issues, or to update your address and contact information. Go to Medicare’s website or call 1-800-MEDICARE for most other matters.
For example, contact Medicare to check the status of your Part A or B claims, to get assistance comparing Medicare Advantage or Part D plans, or to file a complaint against your private Medicare plan. You can also contact either SSA or Medicare to request a replacement Medicare card. If you have a Medicare Advantage or Part D plan, you should contact your plan directly to learn about its coverage rules and costs, which may differ from those of Original Medicare. Also contact your plan to appeal a coverage decision or to file a grievance, which is a formal complaint usually about poor customer service or administrative errors.
Don’t hesitate to contact your local Health Insurance Counseling and Advocacy Program (HICAP). They specialize in trusted, unbiased, and individualized Medicare counseling around these issues. Your local HICAP also has specialized information specific to your state and county. For example, your local HICAP can help you learn about Medigap enrollment rules in California, compare Medigap costs in your area, and apply for Medicare cost-assistance programs. They can also provide individualized counseling to support you in filing Medicare appeals, deciding to switch Medicare coverage, or understanding general Medicare coverage rules.
Point 4: Know how to identify and report Medicare fraud, errors, and abuse.
Medicare fraud, errors, and abuse involve a wide range of behaviors that result in unnecessary costs to the Medicare program. It is important to recognize potentially fraudulent activities by providers and suppliers. Examples of Medicare fraud might include:
- Someone steals your Medicare number and uses it to bill Medicare for items or services you don’t need and never receive.
- Someone calls you or visits your home to offer you “free” equipment that you do not need and then bills Medicare for the equipment.
- A plan agent uses your Medicare information to enroll you in a plan without your consent.
It is important to protect your Medicare number and only give it to your doctors and other providers. Be careful when others ask for your personal information or offer free services if you provide your Medicare number. Check your MSNs or your EOBs regularly to check for any suspicious charges or errors. Also, remember that providers are not permitted to routinely waive cost-sharing or offer gifts or financial incentives for you to receive services from them. If you see any suspicious charges or have any reason to believe your provider is inappropriately billing Medicare, call your provider to see if they have made a billing error. If you suspect you are experiencing Medicare fraud, errors, or abuse, contact our California Senior Medicare Patrol (SMP) at 1-855-613-7080.
Take Action:
- Contact Medicare or your Medicare Advantage Plan to learn about coverage rules and costs around services you plan to receive.
- Look out for Medicare notices you should receive regularly, like MSNs, EOBs, and ANOCs.
- Contact your local Health Insurance Counseling and Advocacy Program (HICAP) for assistance, education, and individual counseling when issues arise.
- Contact our California Senior Medicare Patrol (SMP) to report potential incidents of Medicare fraud, abuse, or errors at 1-855-613-7080.
This blog was edited from the 2021 July Medicare Minute article written by Medicare Rights Center, SMP National Resource Center and SHIP National Technical Assistance Center.
