Medicare offers comprehensive healthcare coverage for seniors 65 years of age and older. But needless to say, it can be confusing. Prior-authorizations, coverage gaps, co-insurance, part D, advantage plans? It can be too much. Here’s the catch – if you don’t know how to successfully navigate the system, you will more than likely be paying too much out of pocket.
But GoodRx is here to help. We spoke with Star Harris, a GoodRx Advocate who’s previously worked for Medicare insurers and has a ton of experience helping people navigate this confusing system. Here are her top 8 tips to help you make the most of your Medicare plan.
Always appeal coverage denials
What you may not realize is that you have the ability, and the right, to appeal any coverage decision made by Medicare – and the odds are in your favor. You can appeal Medicare and request changes to coverage or payment for a medical service or prescription drug. Appeals are the most successful when your doctor deems your treatment is medically necessary, or you have reason to believe that there was a clerical error leading to your coverage denial.
One of the best ways to build your appeal case is to get your doctor’s input. Talk to your provider about any backup documentation, or medical notes, that could help you prove your treatment of prescription is medically necessary. Persistence is also key. Even if you get denied once, you can appeal up to three more times.
Need help with filing an appeal? Contact your State Health Insurance Assistance Program (more on that below). These programs are especially important if you are appealing for a second, third, or even fourth time.
For more information submitting an appeal, read here.
Take advantage of free preventative care benefits
Americans only use preventative services at about half the recommended rate. While they can be costly, they can help you avoid serious health conditions. But for those of you who have Medicare coverage, preventive services like screenings and routine vaccinations are free and you will not be charged a copay, coinsurance, or deductible. Examples of covered services include diabetes screening and management training, preventative shots, tobacco cessation counseling, cancer screenings, and mammograms.
One yearly wellness visit is also covered under these preventative care benefits to help you stay up-to-date on your current health and risk factors. Services covered in this yearly wellness visit include routine measurements, review of medical and family history, and recommendations for necessary preventative and treatment services. This benefit is especially important for those with chronic health issues like diabetes or cardiovascular conditions.
For more information on these preventative care benefits, and to see what is covered, read this guide here.
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Questions about your plan? Go straight to your provider
Rather than trying to use Medicare.gov to answer your questions, if you have an Advantage Plan, go straight to your insurance provider. This is especially important during enrollment season when traffic is high, and the Medicare.gov site might be slower. Another benefit of using your plan’s site – you won’t have to log in to see plan details.
Take advantage of your state’s counseling program
All 50 states offer free personalized counseling, called State Health Assistance Programs (SHIP), to help you answer questions about coverage, appeals, enrollment, and Medicare complexities. What’s more, SHIP counselors can also guide you through ways to save on your plan and can suggest additional special programs that can subsidize your expenses. For more information, and details about your states’ counseling program, visit https://www.shiptacenter.org/
See if you qualify for programs that can help pay your Medicare expenses.
If you are having trouble affording your Medicare costs, see if you are eligible for a financial assistance program. These programs can help cover the cost of premiums, coinsurance, copayments, and some are even available for those in U.S territories like Puerto Rico or Guam.
If you have any questions or want assistance on finding a program that may be right for you, read over this guide, or discuss your options with your state’s counseling program mentioned above.
Enrolled in employer insurance? Pay attention to how it works with Medicare
This is important if you are still receiving coverage from your employer. Medicare can be either primary or secondary to your employer insurance, but this will depend on if you are working, the size of the employer, and other factors. If Medicare is your primary payer, it will pay first and your employer will kick in if there are any costs not covered by Medicare.
Understanding how your two plans work together is important, especially during enrollment. For more information on how Medicare coordinates with other coverage, read here.
Shop around for a new Medicare Part D plan every year
Medicare Part D is the prescription drug benefit that subsidizes the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries. But different plans have different lists, or formularies, of the drugs they’ll pay for – so you want to be sure you’re on a plan that best covers your medicines. Despite this, only 1 in 10 seniors change their plan every year. Even if you’re happy with your current plan, it can pay to shop around – especially if your medications have changed, and you will require different coverage next year. If you plan on shopping around, the Medicare Plan Finder is your best resource.
Watch out for your new Medicare card
Within the next year, look out for your new Medicare card. In an attempt to keep your information private, social security numbers will now be removed from Medicare cards. Don’t worry if you don’t get your new card for some time, your old card will still work.