Here’s an updated list of frequently asked questions from our Medicare clients. For the most up-to-date and specific information, I recommend contacting Medicare.gov, 1-800-MEDICARE, or your local STATE HEALTH INSURANCE PROGRAM to get information on all of your options.

 

Question 1:

What should I do if the doctor listed on my member card is incorrect?

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Answer: If the information on your Medicare Advantage membership card, particularly the listed doctor, is incorrect, it's important to take the below steps to address the issue.

 

Contact your Medicare Advantage Plan:

• Call the customer service number provided on your Medicare Advantage member card. Explain the situation and inform them that the information, particularly about the listed doctor, being incorrect. They should be able to investigate, correct the error and provide you with a replacement card.

Verify your Enrollment Information:

• Ensure that the information on your enrollment with the Medicare Advantage plan is accurate. Check any confirmation documents or communications you received about the plan from your broker during the enrollment process.

Update your Information:

• Provide the correct information about your doctor to the Medicare Advantage plan. They may have a specific process for updating member information, and they will guide you on the necessary steps.

Request a New Member Card:

• Once the correct information is updated in the plan's system, request a new member card with the accurate details, including the correct doctor's information. With some Medicare plans, you can log onto their website and download a temporary card.

Double-Check Provider Directories:

• Review the provider directories provided by your Medicare Advantage plan to ensure that your correct doctor is listed. These directories are often available online or in print, and they contain information about the healthcare providers covered by the plan.

Document the Correction:

• Keep a record of your communications with the Medicare Advantage plan regarding the correction. Note the date and time of your calls, the names of the representatives you spoke with, and any reference or confirmation numbers provided.

Follow-Up:

• If the correction is not reflected on your new member card or in the provider directories within a reasonable timeframe, follow up with the Medicare Advantage plan to ensure the issue is resolved. Contact your broker for additional assistance. Visit our home page and click on consultation to schedule assistance.

 

 

Question 2:

What should I do if I receive a bill while covered on a Medicare Advantage plan or Medicare and Medi-Cal (dual eligible)?

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Answer: Carefully review the bill to understand the services provided, the amount billed, and any explanations of benefits (EOBs) that accompany the bill.

 

Contact the Provider:

• Reach out to the healthcare provider listed on the bill. It's possible that there was a billing error or that they haven't received payment from Medicare. Ask for an itemized statement if you haven't received one.

Verify Medicare Coverage:

• Confirm that the services listed on the bill are covered by Medicare. Some services may not be covered, and you may be responsible for those costs. Check your Medicare coverage guidelines or contact Medicare directly for clarification.

Contact Medicare:

• If you believe the bill should have been covered by Medicare and there is an issue, contact Medicare. You can call 1-800-MEDICARE (1-800-633-4227) to speak with a representative or visit the official Medicare website for assistance.

File an Appeal:

• If Medicare denies coverage for a particular service, you have the right to file an appeal. Follow the instructions on your MSN or contact Medicare for guidance on the appeals process.

Check Supplementary Coverage:

• If you have additional coverage through a Medigap (Medicare Supplement) plan or a Medicare Advantage plan, check whether the bill should have been covered by your supplementary insurance. Contact your insurance provider for assistance.

Preventive Services:

• Keep in mind that some preventive services may have cost-sharing, such as deductibles or coinsurance. Verify the details of your coverage for specific services.

Report Fraud or Billing Errors:

• If you suspect fraudulent billing or errors, report it to Medicare. They have processes in place to investigate and address such issues.

Seek Assistance:

• If you're having difficulty resolving the billing issue, consider seeking assistance from your State Health Insurance Assistance Program (SHIP) or a local Medicare counseling office. Lastly, contact your broker for additional help.

• It's crucial to address billing issues promptly to prevent any potential financial burdens. Being proactive and seeking clarification from both the healthcare provider and Medicare can help resolve billing discrepancies.

 

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Question 3:

What is the difference between Medicare Parts A and B?

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Answer: Medicare consists of different parts that cover specific aspects of your healthcare. Here's a brief overview of the difference between Medicare Parts A and B:

 

Medicare Part A - Hospital Insurance:

• Covers inpatient hospital stays.

• Includes skilled nursing facility, hospice, and some home health care services.

• Generally, does not require a monthly premium if you or your spouse paid Medicare taxes while working.

Medicare Part B - Medical Insurance:

• Covers outpatient care, doctor visits, preventive services, and some home health care.

• Requires a monthly premium, which is based on your income.

• Generally, covers 80% of approved services, and you are responsible for the remaining 20% after meeting the annual deductible.

• In summary, Part A focuses on inpatient hospital services, while Part B covers outpatient and medical services. Most people eligible for Medicare choose to enroll in both Part A and Part B to ensure comprehensive coverage for both hospital and medical needs.

 

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Question 4:

How do I enroll in Medicare for the first time?

 

Answer: Enrolling in Medicare depends on your eligibility and many other health related circumstances. Here's a general guide on how to enroll in Medicare.

 

Automatic Enrollment:

• If you're receiving Social Security benefits when you turn 65, you will be automatically enrolled in Medicare Parts A and B. You'll receive your Medicare card in the mail about three months before your 65th birthday.

Manual Enrollment:

• If you're not receiving Social Security benefits, you need to manually enroll in Medicare.

• You can apply online through the Social Security Administration's website, visit your local Social Security office, or call Social Security at 1-800-772-1213.

Enrollment Periods:

• Initial Enrollment Period (IEP): This is the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after your 65th birthday.

• General Enrollment Period (GEP): If you missed your IEP, you could enroll during the GEP, which runs from January 1 to March 31 each year. Keep in mind that you may face a late enrollment penalty.

Special Enrollment Periods (SEP):

• You may qualify for an SEP if you have certain life events, such as retiring from a job with employer-sponsored health coverage. The most used is relocating to another plan area and due to a disaster.

• It's crucial to understand your enrollment window to avoid potential penalties and gaps in coverage. If you have specific questions or need personalized assistance, you can visit our home page and schedule a consultation to discuss information tailored to your specific situation.

 

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Question 5:

What is the Medicare Advantage Open Enrollment Period?

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Answer: The Medicare Advantage Open Enrollment Period (OEP) starts on January 1st and ends March 31st. During which individuals who are already enrolled in a Medicare Advantage plan can make changes to their coverage. Here are some key details about OEP.

 

Enrollment Period/Timing:

• The MA OEP takes place from January 1 to March 31 each year.

Who Can Make Changes:

• Individuals who are already enrolled in a Medicare Advantage plan (Medicare Part C) can use this period to make certain changes to their coverage.

Permitted Changes:

• During the MA OEP, individuals can switch from one Medicare Advantage plan to another.

• They can also disenroll from their current Medicare Advantage plan and return to Original Medicare (Part A and Part B) beginning the next month. If they choose to do so, they also have the option to join a stand-alone Medicare Prescription Drug Plan (Part D) or continue without creditable drug coverage a be subject to future penalties.

Limitations:

• Changes made during the MA OEP are generally limited to one election. Subsequent changes are not allowed unless the individual qualifies for another enrollment election period.

Prescription Drug Coverage:

• If an individual switches to Original Medicare (Part A and Part B) during OEP, they could enroll in a stand-alone Medicare Part D prescription drug plan.

• It's important for individuals to review their healthcare needs and current Medicare Advantage plan during OEP to determine if any adjustments are necessary. Keep in mind that this period is distinct from the Annual Enrollment Period (AEP), which occurs from October 15th to December 7th each year and allows for various Medicare-related changes, including selecting or changing Medicare Advantage and Part D plans.

 

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Question 6:

How does Medicare cover preventive services?

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Answer: Medicare covers a range of preventive services to help beneficiaries maintain their health and detect potential issues early on. Here are some key points about how Medicare covers preventive services.

 

Medicare Preventive Visit:

• Within the first 12 months of enrolling in Medicare Part B, beneficiaries are entitled to a "Welcome to Medicare" preventive visit. This visit includes a review of health and education on preventive services.

Annual Wellness Visit:

• After the first year, beneficiaries are eligible to an Annual Wellness Visit, which focuses on developing or updating a personalized prevention plan.

Preventive Services Covered by Medicare:

• Medicare covers a variety of preventive services, including but not limited to:

• Vaccinations (e.g., flu shots, pneumococcal vaccines).

• Screenings for various conditions (e.g., cancer screenings, diabetes screenings).

• Cardiovascular screenings.

• Bone density measurement.

• Counseling for tobacco cessation.

• Many preventive services are provided at no cost to the beneficiary. This means there is no deductible or coinsurance required for these services. Be sure to visit Medicare.gov or your doctor to confirm.

Early Detection and Prevention:

• The goal of these preventive services is to detect health issues early or prevent them altogether, promoting overall well-being.

Coverage for Certain Tests and Screenings:

• Medicare covers specific tests and screenings based on age, gender, and risk factors. For example, mammograms, Pap tests, and colorectal cancer screenings are covered.

• It's important for Medicare beneficiaries to work with their healthcare providers to schedule recommended preventive services.

• Staying up to date with preventive care can contribute to better health outcomes and overall quality of life. However, coverage details can vary, so it's advisable to check with Medicare or the healthcare provider for specific information based on individual circumstances.

 

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Question 7:

Are there income limits for Medicare eligibility?

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Answer: Medicare eligibility is primarily based on age and certain medical conditions, and there are generally no income limits for most Medicare beneficiaries. Here are the key criteria for Medicare eligibility:

 

Age Eligibility:

• Individuals are generally eligible for Medicare at age 65. This includes eligibility for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).

Qualifying Medical Conditions:

• Individuals under the age of 65 may also qualify for Medicare if they have certain disabilities or medical conditions, such as end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS). In addition, under the age of 65 and being deemed on permanent disability of a consecutive 24 months.

Work History and Premium-Free Part A:

• Most people qualify for premium-free Medicare Part A if they or their spouse worked and paid Medicare taxes for a certain period.

Income Limits for Part D Extra Help:

• While there are no income limits for basic Medicare eligibility, there are income limits for the Part D Low-Income Subsidy (LIS) program, also known as Extra Help. This program helps individuals with limited income and resources afford prescription drug coverage. Schedule a consultation to learn more details.

• It's important to note that income may affect the costs associated with Medicare, such as Part B premiums and the Part D income-related monthly adjustment amount (IRMAA) for higher-income individuals.

• For the most accurate and up-to-date information on Medicare eligibility based on income, it's recommended to check with the Social Security Administration or visit the official Medicare website.

• Additionally, individuals with specific circumstances, such as those eligible for Medicare due to disabilities, should review eligibility criteria based on their unique situation.

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Question 8:

Can I change my Medicare plan during the year?

 

Answer: In general, Medicare beneficiaries have specific periods during which they can make changes to their Medicare plans. However, there are certain circumstances that may allow for changes outside of these designated enrollment periods. Here are the primary periods when you can change your Medicare plan:

 

Annual Enrollment Period (AEP):

• The Annual Enrollment Period occurs from October 15th to December 7th each year. During this time, you can make various changes to your Medicare coverage, including:

• Switching from Original Medicare (Part A and Part B) to a Medicare Advantage plan (Part C).

• Switching from a Medicare Advantage plan back to Original Medicare.

• Changing or enrolling in a standalone Medicare Part D prescription drug plan.

Medicare Advantage Open Enrollment Period (MA OEP):

• The Medicare Advantage Open Enrollment Period takes place from January 1st to March 31st. During this period, individuals already enrolled in a Medicare Advantage plan can make certain changes, such as switching to another Medicare Advantage plan or returning to Original Medicare.

Special Enrollment Periods (SEPs):

• SEPs are available in specific situations, allowing you to make changes outside of the standard enrollment periods. Examples of qualifying events for SEPs include moving to a new area, losing other health coverage, or qualifying for Extra Help with prescription drug costs.

5-Star Special Enrollment Period:

• If you are enrolled in a Medicare Advantage plan or a Part D prescription drug plan that receives a 5-star rating from Medicare, you may be eligible for a 5-Star Special Enrollment Period. This allows you to enroll in or switch to a 5-star rated plan at any time during the year.

• Outside of these enrollment periods or qualifying events such as relocating, you typically cannot make changes to your Medicare plan during the year. It's advisable to review your healthcare needs and plan options during the designated enrollment periods to ensure your coverage aligns with your health requirements.