A Medicare advocate can help you understand Medicare and your rights under the various plans. They can also help with coverage, enrollment, appeals, and eligibility for other programs.
It is important to have an unbiased source to turn to for help navigating Medicare, and a Medicare advocate can fill this role.
A Medicare advocate can help both beneficiaries and their caregivers even before someone becomes eligible for Medicare. They can help them decide on the type of coverage they need, guide them through the enrollment process, and ensure they get all the benefits to which they are entitled.
They can also help them feel empowered to make confident healthcare decisions.
Medicare is available to most people age 65 and over and to some people under age 65 with specific medical conditions.
Medicare can be a complex area to navigate. Having knowledgeable people and organizations to help you is vital to ensuring you get the best care.
Advocates can help:
- bridge the gaps between Medicare beneficiaries and healthcare professionals and facilities
- find the right plan for your inpatient and outpatient care needs
- get answers to questions relating to your plan benefits, coverage, out-of-pocket costs, and limits
- raise appeals to coverage decisions
- make sense of complex Medicare rules and regulations
- empower you with information on your rights under Medicare
Local and state-specific organizations may advocate for Medicare beneficiaries. You can contact your state office to find the services available to you.
However, one of the main places to get information and access advocate services is through the State Health Insurance Assistance Program (SHIP).
State Health Insurance Assistance Program (SHIP)
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 individual state offices and local agencies to create community-based counselor networks that can provide help in person and over the phone. They also use multimedia sources to educate people about Medicare.
You can find your regional SHIP center using their 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 you need further help and advice, here are some of the avenues available to you.
The Medicare beneficiary ombudsman
The Medicare Beneficiary Ombudsman can help with Medicare-related complaints, grievances, and information.
The service ensures your rights and protections are upheld and that your concerns are addressed.
If you are experiencing difficulties with Medicare or your plan, you can contact Medicare at 800-633-4227 (TTY: 877-486-2048), who will forward your query to the Medicare Beneficiary Ombudsman.
The beneficiary and family-centered care quality improvement organization (BFCC-QIO)
The BFCC-QIOs are there to review Medicare complaints and monitor your care quality. BFCC-QIOs aim to improve Medicare’s overall service quality and can help you:
- lodge an appeal
- raise and complaint or grievance
- review your care quality
- review the medical necessity of procedures, items, or services
Livanta or Acentra administers the BFCC-QIO on Medicare’s behalf. Which one 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
- Michigan
- 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
- Iadho
- 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 oversee and inspect 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 you have concerns about inappropriate or unsafe conditions in a hospital, hospice, nursing home, or home health agency.
You can also contact them about the treatment or services that you or someone else received or did not receive in a healthcare setting, including but not limited to:
- abuse
- neglect
- mistreatment
Contact your State Survey Agency for more information.
Medicare is a type of government-funded health insurance that provides medical benefits to people ages 65 and older. Some people under age 65 may qualify for Medicare, including:
- those with a disability who have been getting Social Security disability benefits for 2 years
- people with a disability pension from the Railroad Retirement Board (RRB)
- those 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 you pay for some parts of Medicare, investments, and other funds that Congress authorizes fund Medicare.
Medicare can be your primary insurer, or you can use it 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 you…
- 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
- learn how to file a Medicare claim
- lodge an appeal about a claim or payment decision
- understand what’s covered and what’s 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 you…
- find out if you already have creditable coverage
- find the best time to enroll in a Part D prescription drug plan
- understand the prescription drug coverage you need
- look for Part D prescription drug plans available in your area
Medicare Advantage (Part C)
Medicare Advantage plans include all the benefits of parts A and B, often include take-home prescription medications, and also typically include coverage for extra benefits like fitness, vision, 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 you…
- decide whether Medicare Advantage is a good option for your circumstances
- 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
If you have Original Medicare, you 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 you…
- 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 ensure you get the correct coverage and benefits and that your rights are upheld under Medicare.
SHIP centers, which are available across the United States, can help with many Medicare-related queries. Other local agencies and organizations may also be accessible to offer help. You can contact your local state office for further information.