Blog

First, learn Medicare coverage rules to avoid running into issues.

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 certain criteria. A service may also not be covered if it is an excluded service, such as a cosmetic surgery.

To learn about Original Medicare’s coverage of a needed service, call 1-800-MEDICARE or visit www.medicare.gov, read the relevant sections of your Medicare & You handbook, or speak with your provider. To learn about how your Medicare Advantage Plan covers a service, call your plan or read your plan’s handbook.

You can also call your State Health Insurance Assistance Program, or SHIP, to learn more about your Medicare coverage rules and state-specific information. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted). 

Reading and understanding your Medicare notices is a great way to identify issues that do arise.

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.

Check your MSNs or your EOBs regularly to check for any suspicious charges or errors. If you see any suspicious or confusing charges, call your provider and your plan to learn more information and to see if there have been any billing errors.

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 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.

These are just a few examples of common Medicare notices you may receive. When you receive any other Medicare notices, take your time reading and understanding them. If you need help understanding a Medicare notice, you can call your SHIP for individual counseling. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted). 

Finally, know who to contact when issues do arise.

There are a few different places you can contact, depending on your issue 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 call Medicare to request a replacement Medicare card, or you can request a new card be sent to you from your my Social Security account. You can also print a replacement Medicare card yourself from your online Medicare account.

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.

And of course, don’t hesitate to contact your local State Health Insurance Assistance Program, or SHIP. They specialize in trusted, unbiased, and individualized Medicare counseling around these issues. Your SHIP also has specialized information specific to your state. For example, your SHIP can help you learn about Medigap enrollment rules in your state, 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. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted). 

Still have questions?  

Your SHIP is here for you! You can contact your SHIP for questions about your Medicare coverage and any problems that arise with it. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.)  

Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).