Common Issues with Medicare Coverage

 Posted on December 26, 2024 in Elder Law

Medicare is a government health insurance program for people aged 65 and older and some younger people with disabilities. It has several parts, including Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage Plans), and Part D (prescription drug coverage). Many people struggle to understand what is covered under each part, which can lead to confusion about medical bills and coverage options.

A Texas elder law attorney can help by explaining the different parts of Medicare and reviewing your coverage to ensure you are not missing benefits or paying for unnecessary services. They can also help you determine whether a Medicare Advantage Plan or a supplemental insurance plan is the right choice for your needs and assist you if you are denied coverage. 

Denied Claims and Coverage Disputes

Sometimes, Medicare denies a claim for a medical service, saying it is not covered or is not medically necessary. This can leave people with unexpected and significant medical bills. Medicare claim denials are often due to paperwork errors or misunderstandings about the rules.

An attorney can assist with the appeals process and will gather the necessary medical records, prepare the appropriate forms, and argue your case to Medicare. With an attorney’s guidance, you have a better chance of getting the coverage you deserve.

Problems with Enrollment Periods

Medicare has specific times when you can enroll, make changes, or sign up for additional coverage. Missing these enrollment periods can result in penalties, higher premiums, or gaps in coverage. For example, if you do not sign up for Part D drug coverage when you are first eligible, you may face a lifetime penalty.

A Medicare attorney can help you understand enrollment deadlines and requirements. They can also assist if you have missed a deadline by helping you file an appeal or determine whether you qualify for a Special Enrollment Period due to unique circumstances, such as moving or losing other health coverage.

High Prescription Drug Costs

Even with Medicare Part D, the cost of prescription drugs can be overwhelming for some people. Many do not understand how the system works, including the coverage gap known as the "donut hole." This gap means you may pay more out-of-pocket for drugs after a certain spending limit is reached.

An attorney can explore ways to reduce these costs, such as applying for programs like Extra Help, which is a federal program that assists with prescription drug costs. They can also check if your drugs are listed on a preferred tier under your plan or help you switch to a plan that better meets your needs.

Problems with Long-Term Care

Many people mistakenly believe that Medicare covers long-term care, such as stays in nursing homes or ongoing home care. In reality, Medicare only covers short-term care for rehabilitation or recovery. Long-term care is typically paid out-of-pocket, through long-term care insurance, or by qualifying for Medicaid, which has strict financial eligibility requirements.

An elder law attorney can help you plan for long-term care costs by setting up tools like trusts or reviewing eligibility for Medicaid. They can also guide you through the complex process of applying for Medicaid if you or a loved one needs long-term care.

Contact a Denton County, TX Elder Law Attorney

If you are facing challenges with Medicare or need help planning for healthcare and long-term care, contact the Flower Mound, TX Medicare lawyer at Colbert Law Group PLLC. Our knowledgeable attorney can help you understand your options and protect your financial future. Call 972-724-3338 today to schedule a consultation.