In this issue
Know Your Medicare Rights: What to Do If Medicare Says “No”
A “not covered” message isn’t the end. There are steps you can take to get answers.
Getting to Know Your Medicare Rights
Each month, we talk about one of your Medicare rights and what it means for you. Knowing your rights can help you feel more confident about your care.
Imagine this:
You go to the doctor to get something checked. The visit may be for something new or something you’ve been dealing with for a while, and you want to get some advice about it. After you and your doctor talk about what’s happening, your doctor decides to order a test or prescribe a new medication. Everything seems straightforward.
Later, you get a phone call, or you’re standing at the pharmacy, and you hear these words:
“It’s not covered.”
Wait… what?
In that moment, it’s easy to feel frustrated and unsure what to do next. Do you say, “No, thank you,” and just walk away, hoping that whatever is going on with you works out okay without doing anything? Do you pay?
Here’s the good news: You have options, and you don’t have to figure it out on your own.
The first step is simple. Whether you have Original Medicare or a Medicare Advantage plan, start by calling your doctor’s office or billing department.
There’s a chance that the “it’s not covered” message you heard was because of a billing issue. Something might have been coded incorrectly when your doctor’s office submitted it, or your plan may need more information.
When you call, you don’t need to have all the right terms. Just ask:
- “Could this be a billing or coding issue?”
- “Can this be resubmitted?”
- “What should I do next?”
You might be surprised how often that solves the problem.
If your doctor’s office can’t fix the issue and you’re told you need to file an appeal, your next step is to contact Medicare (for Original Medicare) or your Medicare Advantage plan. They can explain what to do and walk you through your options.
For Original Medicare, call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048. With this plan, you can appeal. That simply means asking Medicare to take another look at the decision. Maybe they didn’t have all the information or something was misunderstood. Either way, you have the right to ask.
You don’t always have to wait for a notice in the mail to take action. If you are told at the doctor’s office, pharmacy, or when scheduling a test that something was denied or not covered, ask what can be done right away. Your doctor’s office may be able to send more information, fix the claim, or help you decide if you should file an appeal.
At some point, you’ll get a notice in the mail that explains everything:
- If you have Original Medicare, it’s called a Medicare Summary Notice (MSN)
- If you have a Medicare Advantage plan, it’s called an Explanation of Benefits (EOB)
These notices show what was billed, what was paid, and what wasn’t. They also tell you how to take the next step if you decide to appeal.
Not sure what type of Medicare you have? You’re not alone. A quick way to check is your card:
- If your card is red, white, and blue, it usually means Original Medicare
- A card from a company like UnitedHealthcare, Humana, Aetna, or Blue Cross typically means you have a Medicare Advantage plan.
If you do have a Medicare Advantage plan, the process is a little different. These plans handle their own appeals, so you’ll want to follow the instructions on your EOB or call the number on your card.
The important thing to remember is this: A “no” isn’t always the final answer. Sometimes it just means, “We need to take another look.”
May is Older Americans Month: Try Something New This Spring
Trying something new can be as simple as showing up. You might be surprised who you meet along the way.
Spring is here, and it’s the perfect time to shake things up.
Is there something you’ve been meaning to try, but keep putting off, such as a class, a new hobby, or a place you’ve never been? This month is your reminder that it’s time to make time for you.
You’ve spent lots of time showing up for and supporting others. How about taking some time just for yourself by doing something fun, interesting, or a little outside your comfort zone?
If you’re thinking, “I don’t have anyone to go with,” you’re not alone. You don’t need a big group to get started. Sometimes it’s as simple as showing up at a local event, a class, or even reaching out to reconnect with someone over lunch now that the weather is warming up.
Self-care isn’t just about rest. It’s also about joy, curiosity, and trying something new. This May, take advantage of the longer days and fresh energy of the season. Say yes to something different and give yourself permission to enjoy it.