Medicare Resource Guide
Questions to Consider When Making Medicare Coverage Decisions
When you are choosing between Original Medicare and Medicare Advantage, or among Medicare Advantage Plans, here are some questions to keep in mind.
Providers, Hospitals, and Other Facilities
• Will I be able to use my doctors? Are they in the plan’s network?
• If my providers are not in network, will the plan still cover my visits?
• Which specialists, hospitals, home health agencies, and skilled nursing facilities are in the plan’s network?
Access to Health Care
• What is the service area for the plan?
• Do I have any coverage for care received outside the service area?
• Who can I choose as my primary care provider (PCP)?
• Does my doctor need to get approval from the plan to admit me to a hospital? • Do I need a referral from my PCP to see a specialist?
Costs
• What costs should I expect for my coverage (premiums, deductibles, copayments)?
• How much will I have to pay out of pocket before coverage starts (what is the deductible)?
• How much is my copayment for services I regularly receive, such as PCP or specialist care? • How much will I pay if I visit an out-of-network provider or facility?
• Are there higher copays for certain types of care, such as hospital stays?
• Am I eligible for any Medicare cost-saving programs, such as a Medicare Savings Program?
Benefits
• Does the plan cover any services that Original Medicare does not (such as dental, vision, or hearing)? • Are there any rules or restrictions I should be aware of when accessing these additional services?
Prescription Drugs
• Does the plan cover outpatient prescription drugs?
• Are my prescriptions on the plan’s formulary?
• Does the plan impose any coverage restrictions?
• What costs should I expect to pay for my drug coverage (premiums, deductibles, copayments)? • Will I be able to use my pharmacy?
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Your Medicare Resources
Medicare is a complex and beneficial program, and a variety of trusted sources can help you navigate your rights and options. A few are listed below.
Medicare
Contact Medicare for information about Original Medicare’s coverage rules, to find a provider or supplier who works with Original Medicare, or to find private Medicare Advantage Plans available in your area. You can also contact Medicare to ask for copies of coverage rules. To speak to a Medicare representative, call 1-800-MEDICARE (633-4227). To find a provider who accepts Original Medicare, you can also use Medicare’s Physician Compare tool: www.medicare.gov/physiciancompare.
Social Security Administration (SSA)
Contact SSA to enroll in Medicare Parts A and B. You should speak to an SSA representative if you are enrolling using your Initial Enrollment Period (IEP), the General Enrollment Period (GEP), or a Part B Special Enrollment Period (SEP). To speak to an SSA representative, call 800-772-1213 or visit your local Social Security office. You can also visit their website: www.ssa.gov.
State Health Insurance Assistance Program (SHIP)
Contact your SHIP if you have questions about Medicare coverage rules or denial notices you have received. SHIP counselors can help explain Medicare coverage, Medicare supplemental insurance policies (Medigaps), coordination of benefits, the appeals process, and much more. You can also contact your SHIP to learn about programs that help lower Medicare costs for people with limited incomes. Visit www.shiptacenter.org or call 877-839-2675 to contact your SHIP.
Medicare Advantage or Part D Plan
Contact your plan if you have questions about your plan’s coverage rules, or for information related to a denial of coverage. A plan representative can also help you find providers and pharmacies in the plan’s network. To speak to a plan representative, call the number on the back of your plan benefits card.
State Department of Insurance
Contact your state’s Department of Insurance if you need assistance navigating Medigap policies and enrollment. They should be able toanswer questions related to availability and enrollment rules in your state.
Senior Medicare Patrol (SMP)
Contact your local SMP if you suspect you have been a victim of Medicare fraud or attempted fraud. SMP representatives can teach you how to prevent, detect, and report potential Medicare fraud, errors, and abuse. To contact your SMP, call 877-808-2468 or visitwww.smpresource.org.
Medicare Rights Center
Medicare Rights is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities.
Medicare Rights’ counselors can help you understand your Medicare benefits, answer enrollment questions, and explain how any existing coverage you have works with Medicare. To speak to a counselor, call Medicare Rights’ toll-free national helpline at 800-333-4114.
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