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Q: Who should I contact if I have an issue with my Medicare coverage?
A: You’ve done the legwork – and compared benefits and premiums. After researching your options, you’ve enrolled in a Medicare plan and begun using your coverage. But what should you do if the plan won’t cover your medication or pay for a doctor’s visit, or there’s a problem paying your premium? Here’s a summary of your options when you have enrollment or billing issues or want to change your plan.
Most beneficiaries don’t have trouble enrolling in Medicare Advantage or Part D coverage. But enrollment problems can occur if you provided information while signing up that doesn’t match what’s in Medicare’s system. For example, problems could occur if you misspelled your name or inverted digits in your Social Security number. You can usually fix those issues by contacting the insurer or a broker (if you used one to sign up).
Enrollment problems can also happen if Medicare has incorrect information about you on file. If you suspect that might be the case, contact the Social Security Administration at 1-800-772-1213 and make sure your name, birthdate and address are accurate in Social Security’s system. (Medicare receives its information from Social Security.)
Insurers can only enroll you in their Medicare Advantage or Part D plan if you’re currently eligible to sign up. You’re allowed to enroll only at certain times, such as when you first qualify for Medicare, during the general enrollment period, fall open enrollment, Medicare Advantage open enrollment, or a special enrollment period (SEP). If you aren’t within one of those windows, you won’t be able to sign up for a plan now.
Medicare will decide whether or not you’re eligible for a SEP based on your circumstances. Unfortunately, you won’t be able to appeal if Medicare denies your request. But you could resubmit your request if Medicare’s decision was incorrect (according to Medicare’s rules).
A Medicare Advantage plan may deny – or choose not to cover – the medical services you receive. You have 60 days from receiving a denial letter to appeal the denied services by sending your carrier a letter. Although you don’t have to, it helps to include a statement from your doctor supporting the “medical necessity” of services the plan denied.
Your plan usually has 30 days to respond to your appeal, but some circumstances require it to get back to you more quickly. (Here are the steps to take if the service continues to be denied. )
If your Part D plan won’t cover a medication, you can try asking your physician to prescribe another drug that’s more likely to be covered. If that isn’t an option, you can file an “exception request” with your Part D plan. This is the first step in a prescription drug appeal. As with medical appeals, it helps to have your doctor write a letter saying the medication is “medically necessary” for you.
Your Part D plan normally has 72 hours to respond to your request – but must respond within 24 hours if your doctor says delays might harm you. If the plan denies your exception request, you have 60 days to appeal.
Put another way, you can file an initial Part D appeal, and if that isn’t approved, then you can file a more formal appeal. (Here is more information about Part D appeals.)
Be sure to include your name, date of birth, Medicare I.D. number, address, the name of the medication or service, and the reason you’re seeking coverage in a medical and prescription drug appeal.
If your Medicare Advantage or Part D plan has inaccurate information about you (your name, date of birth, or address), you should contact Social Security to update that information. You will also want to reach out to your insurer to make sure they are aware so that you do not miss out an any correspondence while waiting for Social Security to update their information.
Likewise, if your plan is having a problem with billing or premium payments, you should call Social Security, and also contact your insurer to ask how you can help them update their information. Your insurer may be able to notate your account with the correct information while Medicare processes your updates. (The insurer’s phone number should be listed on your member I.D. card.)
You should also contact the insurer to change how you pay for your coverage, such as establishing direct debit from a bank account or allowing premiums to be deducted from your Social Security benefits.
You can switch to another Medicare Advantage or Part D plan by calling 1-800-MEDICARE, visiting Medicare.gov, or contacting the new insurer. When you change to a new Medicare plan, your old plan will end when the new coverage begins. An agent or broker can also help you change your plan. (If you used a broker, they could also help with filing an appeal if your plan doesn’t cover a service or medication.)
Medicare beneficiaries usually can only change Medicare Advantage or Part D plans during an open or special enrollment period. However, beneficiaries who also have a Medicare Savings Program, Medicaid, or Supplemental Security Income receive Extra Help, which allows them to can change their plan each quarter. (Extra Help enrollees can change plans quarterly from January through September. From October and December, enrollees can make changes during fall open enrollment.)
If you’re making changes related to a Medigap policy, you can only make those through an insurer. The exception is if you’re updating the information Medicare has about your Medigap carrier, so claims will automatically “cross-over” between Medicare and the Medigap insurer. You would call Medicare to update the information it has for your Medigap plan.
It’s usually not a good idea to cancel your Medicare Advantage or Part D plan without having coverage to replace it. This could cause you to face large out-of-pocket expenses.
If you don’t have other coverage, and you’re struggling to afford your plan’s premiums, your insurer might agree to payment arrangement. And if you’re struggling to afford Medicare’s premiums, help is often available through a Medicare Savings Program.
You also shouldn’t leave your Part D plan if you don’t have replacement coverage that is “creditable.” This means coverage that is at least as comprehensive as Medicare prescription drug benefits. If your new coverage isn’t creditable, you’ll owe a premium penalty if you sign up for Part D in the future.
But you are allowed to disenroll from Part D coverage anytime if you’re replacing it with creditable coverage. This rule also allows you to leave a Medicare Advantage plan that includes prescription drug benefits.
If you’re certain you want to cancel your Medicare Advantage or Part D plan and are eligible to make changes, you can ask your insurer to disenroll you (or you can do this by contacting 1-800-MEDICARE, visiting Medicare.gov, or using a broker.)
The date your plan ends depends on the enrollment period you use. For example, if you disenrolled during fall open enrollment, your enrollment would end December 31.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare technical assistance contract at the Medicare Rights Center in New York City, and represented clients in Medicare claims and appeals. Josh also helped implement health insurance exchanges at the technology firm hCentive. He has also held consulting rules, including at Sachs Policy Group, where he worked with hospital, insurer and technology clients.