The federal Medicare program assists a vast number of beneficiaries each year. Given its expansive reach, it's unsurprising that some beneficiaries run into challenges or issues that require attention.
At Local Medicare Specialists, we consistently address and navigate Medicare concerns raised by our clients. Our dedicated team of Medicare advisors handles these issues, so our clients have the advantage of having experts on their side.
Let's dive into seven of the most frequent Medicare issues and how we, as Local Medicare Specialists, tackle them.
A lot of medical offices may not possess comprehensive knowledge about the intricacies of Medicare. Medicare Part B has an annual deductible that beneficiaries are responsible for covering. However, with all the different Medicare plans out there, it’s often confusing who is required to pay the Part B deductible and who isn’t.
It's not uncommon for these offices to request payment for the deductible on the day of your visit. However, you might also receive an invoice indicating an outstanding Part B deductible.
The confusion happens because Medicare lacks immediate visibility into the deductible you've already settled with your physician. To resolve the issue, your physician's office needs to submit your claim to Medicare for processing. In cases where this process occurs, Medicare may not acknowledge your deductible payment.
Another scenario happens when you've already cleared your deductible with your doctor, but another service provider, such as a laboratory, bills Medicare ahead of time. Consequently, Medicare processes this claim, excluding the deductible amount, leading to a separate charge for the deductible from that provider. In such instances, you should seek reimbursement from your physician since Medicare applied the deductible to an alternative claim.
Medicare decides your monthly premiums for Part B based on tax returns from two years prior. Beginning in 2024, if your annual income surpasses $103,000 (for a single filer), you're subjected to an increased monthly premium called IRMAA, the Income-Related Monthly Adjustment Amount. This approach can be perplexing for retirees who typically earn less during their retirement years than reflected in their previous tax returns.
If you feel like your income has drastically changed over the last two years, you can submit a request to appeal your IRMAA. The Social Security office will review the form and documents and decide whether or not it is prudent to decrease your Part B premium.
Medicare Advantage plan members encounter copays for various services. For example, while you might expect a copay of $40 for a doctor's visit, additional services like lab work can trigger separate copay charges. Such unpredictability in out-of-pocket costs often exceeds initial budgetary expectations for Medicare Advantage members.
If you enrolled in a Medicare Advantage by yourself and find that you’re encountering unexpected copays, it might mean there is a gap between your plan's coverage and your needs. To address this, Local Medicare Specialists offer solutions tailored to your circumstances. Our expertise allows us to evaluate alternative Medicare Advantage plans within your region, aiming to optimize cost-effectiveness. We can also explore Medigap plans as an alternative, potentially curbing your out-of-pocket expenses.
When you get your prescriptions filled, you might end up with a bill that is higher than you expected. While occasionally the charged amount aligns with the expected cost, discrepancies can occur.
When this happens, we can do a thorough examination to determine the accuracy of your copay. This process often involves contacting your Part D plan provider for clarification. Higher copay amounts might stem from the prescription being classified as a higher-tier drug, which you can see on your drug plan's formulary.
Once we find out the cause, we can resolve it in several ways. One approach involves talking with your physician to request a tier downgrade for your medication with the plan provider. Alternatively, with your physician's guidance, exploring similar medications within a lower tier can help mitigate the cost implications. For example, it’s often much cheaper to switch to a generic drug if possible.
Durable medical equipment (DME) can be tricky. Beneficiaries can’t purchase DME wherever they please. Instead, they must get it from a Medicare-approved supplier. And, if you’re on a Medicare Advantage plan, you must find a supplier that participates with your plan. If you use the correct supplier, Medicare does have coverage for DME.
Check out this recent article we published that talks about how Medicare covers durable medical equipment.
A common misconception among Medicare beneficiaries is the belief that Medigap plans provide coverage for all services and procedures not covered by Medicare. However, Medigap plans solely address the financial gaps associated with Medicare-approved claims, such as deductibles, copays, and coinsurances. Importantly, Medigap coverage activates only after Medicare approves and processes its share of the claim. If Medicare denies coverage for a particular service, the Medigap plan cannot intervene or provide compensation.
A frequent challenge for people moving to Medicare while still working is the assumption that Medicare immediately assumes primary insurance status. After retirement, they might visit healthcare providers and present their Medicare card with the expectation of primary coverage, only to later discover that Medicare denies the claim.
This problem often happens due to Medicare's lack of acknowledgment as the primary insurer, especially if the beneficiary remains enrolled in an employer's health plan post-retirement. If the employer neglects to inform Medicare of the beneficiary's retirement status, Medicare continues to consider itself as the secondary payer following the group insurance.
To rectify this, our team can start a conference call with Medicare, ensuring they recognize their status as the primary insurer for the individual in question. Subsequently, we communicate with the healthcare provider's office and instruct them to resubmit the claim.
Navigating Medicare, like any insurance system, presents its share of unexpected billing complexities. Recognizing and addressing these issues underscores the value of having a dedicated ally such as Local Medicare Specialists by your side.
Our proficient team diligently addresses the concerns of our beneficiaries, ensuring they navigate Medicare's intricacies with confidence and clarity. Why continue to navigate these challenges independently when you can benefit from a team committed to advocating for your needs? Reach out to Local Medicare Specialists today for personalized assistance tailored to your Medicare journey.
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LocalMedicareSpecialists.com is privately owned and operated by LMS Insurance LLC. LocalMedicareSpecialists.com is a non-government resource for those who depend on Medicare, providing Medicare information in a simple and straightforward way.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area which are United Healthcare, Aetna, Humana, Cigna, Blue Cross Blue Shield of Arizona, Centene, Devoted, and Scan. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.