The most common issues you may face after signing up for Medicare

You’ve just finished your last day of work before retirement, you gave yourself plenty of time to sign up for Medicare and get your insurance in place for when you need it to start. In a perfect world there’s nothing else you should have to do except relax and sip cold beverages on a beach somewhere. Unfortunately, that isn’t always the case and you may need to take some additional steps before your Medicare is squared away. At Doctor’s Choice we call these occurrences post enrollment issues and here are some of the most common issues we see and explanations on how to resolve them.

Insurance companies sending you a letter stating you didn’t have creditable coverage

The most common post-enrollment issue we hear from our clients has to do with a letter from your insurance company stating that, you didn’t have creditable prescription coverage for a certain period and may face a penalty as a result. If you’re enrolled in a Part D drug plan, chances are, you’ve received the same exact letter. Unless you actually have had a lapse in coverage for a period of time then you shouldn’t be facing a penalty. This is unfortunately just a piece of what we call “scare mail.”

In most cases, this can be resolved with a simple call to the phone number included on the letter. You will then just need to provide verbal confirmation that you did in fact have creditable coverage and that you have provided all the necessary paperwork to reflect that. In rare cases, you will need to get a letter from the HR department from your employer stating that you did have coverage during the contested period. However, you should have this documentation already since you would have needed it to enroll in Part B. 

Medicare Crossover issue where your old employee plan shows up as primary instead of medicare

Another less common yet no less frustrating issue we’ve seen is after receiving medical services and submitting a claim. Sometimes the claim may get denied because Medicare isn’t showing up as your primary form of insurance. This is known as a Medicare Crossover issue where the Medicare system hasn’t been updated to reflect your active enrollment. Instead, your employer group plan is still showing up as your primary form of insurance. 95% of the time this can be resolved by calling Medicare at 1-800-633-4227.

You will be prompted to answer some personal verification questions and then you’ll be transferred to a representative. Once you are transferred the script to use is this: “I recently received medical treatment and the claim was denied due to Medicare not being my primary insurance. This is not correct. I have been on Medicare since _______(part b effective date) and am no longer covered under my employer group plan and I would like my records to be updated to reflect this.” They can then look into your records and help resolve the issue for you. Once they confirm that Medicare will now show up as your primary form of insurance all you have to do is contact the facility where you received treatment and ask them to resubmit the claim to Medicare. 

Your Doctor was Dropped from the network 

This is an issue that folks may face at some point or another, especially those with Advantage Plans. Advantage plans usually provide coverage and benefits through a network of doctors. These plans can change unexpectedly throughout the year and one of these changes might be a change to the provider network. This can be extremely frustrating because you may not find out until you need care.

There are a couple of routes you can take if this happens to you. If you’re willing to switch to a new PCP, all the doctors in your area who do accept your plan will be listed in the Explanation of Benefits booklet you received from your insurance company. You can simply pick a physician off the list and call them to see if they are accepting new patients. It may be a good idea to confirm that they do in fact accept your Medicare plan (they could have been dropped too!).

If you want to keep your primary care doctor you may have to wait until the Open Enrollment Period (Oct 15th – Dec 7th) to switch into a plan that your doctor does accept. Another option would be to just pay out of pocket or to select a plan that allows you to go out of network. However you may have to pay more in co-pays and deductibles if you do go out of network. This can be a tricky situation to maneuver but knowing some of the avenues you can take can make sorting it out a bit easier.    

Insurance Company Specific problems 

There are countless things that may come up when dealing with health insurance. One of the best pieces of advice we can give is to use the phone number on the back of your cards for issues that may arise. These are customer service lines that deal with the issues you may be having on a daily basis. A phone call to them could sort out your issue or at least give you an idea of what direction you need to go to get the issue taken care of. 

The prices of your Medications went up

This is another common issue many people run into whether on Medicare or not. Unfortunately, there is really not a whole lot you can do about this most of the time due to the nature of the prescription drug market. The Rx Drug market trades like the stock market and prices can fluctuate on a day-to-day basis due to supply and demand. If the price of your drug went up, you’re unfortunately responsible for the additional cost. Some plans may change their formularies mid-year causing your medication to be dropped from coverage.

In this case, you’re again responsible for the costs, although there are some workarounds to this such as enrolling in a 5 Star Part D plan, this may not be any more beneficial than just paying for the medication out of pocket. Most drug companies allow you to contact them and see if they can make a price exception. While this isn’t a guarantee it’s one possible route you could take.  Another possible workaround would be asking your Doctor to prescribe a similar medication or generic alternative that is covered under your plan. 

Sometimes dosages and delivery method can change prices as well, a call to the number on the back of your card can help you figure out the best way to move forward. Another thing to consider if you have a lot of Medication is that you may have fallen into what is known as the coverage gap or donut hole.

As of 2023, once you and your plan spend $4,660 on drugs, you fall into this gap. Once in this gap, you will be responsible for no more than 25% of the cost of brand-name meds and 25% of the price of generics. Once you reach $7,400 in total costs Medicare will come in and pay 95% of the costs of your medications.

Starting in 2024, Medicare will remove the 5% copayments once you reach the $8,000 catastrophic coverage.

Starting in 2025, Medicare will limit your prescription out of pocket expense to $2,000 per year.