A Medicare advocate can help people understand Medicare and their rights under the various plans. They can also help with coverage, appeals, enrollment, and upholding rights.
Medicare advocates are people or organizations that can offer important, unbiased information to help people navigate Medicare.
Medicare advocates can help beneficiaries and their caregivers with Medicare even before someone becomes eligible.
An advocate can help a person decide on their coverage, guide them through enrollment, and ensure they receive all the benefits they are entitled to.
They can also empower them to make confident healthcare decisions.
Medicare is available to most people ages 65 and over and to some people under age 65 with specific medical conditions.
The Medicare landscape can be complex, and having knowledgeable people and organizations there to help is vital to ensuring people get the most suitable care.
Advocates can help:
- bridge the gaps between Medicare beneficiaries and healthcare professionals or facilities
- find the right plan for a person’s inpatient and outpatient care needs
- get answers to questions relating to a person’s plan benefits, coverage, out-of-pocket costs, and limits
- raise coverage decision appeals
- make sense of complicated Medicare rules and regulations
- empower you with knowledge on your rights under Medicare
Local and state-specific organizations can advocate for Medicare beneficiaries, and people can contact their state office to find the services available to them.
However, one of the main places to get information and access advocate services is through the State Health Insurance Assistance Program (SHIP).
SHIPS
SHIPs offer free, impartial Medicare advice and counseling.
They are federally funded by the Administration for Community Living, and its Office of Healthcare Information and Counseling (OHIC) manages SHIP on its behalf.
SHIPs work with state offices and local agencies to create counselor networks that provide help in person and over the phone and use multimedia sources to familiarize people with Medicare.
A person can find their regional SHIP center using its office locator tool or by calling 877-839-2675.
The Center for Medicare Advocacy offers many self-help toolkits on Medicare coverage, appeals, and rights.
If a person needs further help and advice, here are some available alternatives.
The Medicare beneficiary ombudsman
The Medicare Beneficiary Ombudsman can help with Medicare complaints, grievances, and information.
The service ensures an individual’s rights and protections are upheld and their concerns are addressed.
If a person is experiencing difficulties with Medicare or their plan, they can contact Medicare at 800-633-4227 (TTY: 877-486-2048), who will deliver their query to the Medicare Beneficiary Ombudsman.
The beneficiary and family-centered care quality improvement organization (BFCC-QIO)
The BFCC-QIOs review Medicare complaints and monitor a person’s care quality. BFCC-QIOs aim to improve Medicare’s overall service quality, and can help:
- file an appeal
- lodge a complaint or grievance
- review care quality
- review the medical necessity of procedures, items, or services
Livanta or Acentra administers the BFCC-QIO on Medicare’s behalf. Which one you use will depend on the state in which you live.
Livanta administers BFCC-QIO in the following areas:
- California
- Nevada
- Arizona
- Nebraska
- Kansas
- Iowa
- Missouri
- Minnesota
- Wisconsin
- Illinois
- Indiana
- Michican
- Ohio
- West Virginia
- Virginia
- District of Columbia
- Maryland
- Pennsylvania
- Delaware
- New Jersey
- New York
- Hawaii
- Northern Mariana Islands
- American Samoa
- Guam
- Puerto Rico
- Virgin Islands
Acentra administers BFCC-QIO in the following areas:
- Alaska
- Washington
- Idaho
- Oregon
- Montana
- North Dakota
- South Dakota
- Wyoming
- Utah
- Colorado
- New Mexico
- Texas
- Oklahoma
- Louisiana
- Arkansas
- Mississippi
- Tennessee
- Kentucky
- North Carolina
- South Carolina
- Alabama
- Georgia
- Florida
- Maine
- New Hampshire
- Massacheusetts
- Connecticut
- Rhode Island
- Vermont
State survey agencies
State survey agencies inspect and oversee Medicare and Medicaid healthcare facilities. They also investigate complaints to ensure the facilities are adhering to health and safety criteria.
State Survey Agencies can help if a person has concerns about unsuitable or unsafe conditions in a hospital, hospice, nursing home, or home health agency.
Individuals can also contact them about the treatment or services that they or someone else received or did not receive in a healthcare setting, including but not limited to:
- abuse
- neglect
- mistreatment
A person can contact their State Survey Agency for more information.
Medicare is a government health insurance that provides medical benefits to people ages 65 and older. Some people under age 65 may also qualify for Medicare, including:
- People with a disability who have been getting Social Security disability benefits for 2 years.
- Those receiving a disability pension from the Railroad Retirement Board (RRB).
- People with amyotrophic lateral sclerosis (ALS) or end stage renal disease (ESRD) and receive dialysis or have undergone a kidney transplant.
How is Medicare funded?
Taxes, premiums that people pay for some parts of Medicare, investments, and other funds that Congress authorizes fund Medicare.
Medicare can be a person’s primary healthcare insurer or can be used alongside another health insurance plan.
Here’s how the different parts of Medicare work.
Original Medicare
Original Medicare comprises Part A and Part B. Part A covers inpatient care, and Part B covers outpatient medical services and limited prescription medications.
An advocate can help a person
- understand Original Medicare’s enrollment periods
- find the best time to enroll in Medicare Part B
- understand the out-of-pocket expenses associated with Original Medicare
- how to file a Medicare claim
- lodge an appeal about a claim or payment decision
- understand what is and is not covered under Original Medicare
Medicare Part D prescription drug plans
Medicare Part D prescription drug plans cover take-home prescription medications.
An advocate can help a person
- find out if they already have creditable coverage
- find the best time to enroll in a Part D prescription drug plan
- understand the prescription drug coverage they need
- look for Part D prescription drug plans available in their area
Medicare Advantage (Part C)
Medicare Advantage plans include all the benefits of parts A and B, often include take-home prescription medications, and typically include coverage for extra benefits like fitness, optical, or dental.
Private insurers administer Part D prescription drug plans and Medicare Advantage plans, so the additional benefits, costs, and plan availability can vary by insurer and location.
An advocate can help a person
- decide whether Medicare Advantage is a good option for their needs
- explore the types of Medicare Advantage plans available
- understand the out-of-pocket expenses
- find Medicare Advantage plans in your area
- find out about the appeals process for claims or payments
Medicare supplement (Medigap) plans
A person with Original Medicare can get a Medigap plan to cover some of the associated out-of-pocket expenses. Private insurers also administer Medigap plans.
An advocate can help a person…
- understand the different types of Medigap plans available
- understand Medigap plan benefits
- search for Medigap plans in your area
- understand the out-of-pocket costs associated with Medigap plans
Medicare advocates are available to help people get the correct benefits and coverage and ensure that Medicare upholds their rights.
SHIP centers, which are available across the United States, can help with many Medicare-related queries.
Other local agencies and organizations may also be able to help, and a person can contact their local state office for further information.