Ashford Insurance Client Self Help FAQ

You can learn about coverage rules, ask questions about your Medicare Summary Notice (MSN), or check the status of your Part A or B claims. You can also contact Medicare to find forms for filing a Medicare appeal or to let someone speak with Medicare on your behalf. Medicare assists you in comparing the costs and coverage of Medicare Advantage Plans, Part D plans, and Medigap in your area. Medicare staff can even help you enroll in a plan or find healthcare providers and suppliers in your area that participate in Medicare. You should also contact Medicare to request a replacement Medicare card.  

To contact Medicare, you can either call 1-800-MEDICARE or go to www.medicare.gov. On its website, Medicare has some helpful tools to learn about plans and providers: 

• Plan Finder(to compare Medicare Advantage or Part D plans in your area) 
• Physician Compare
• Home Health Care Compare
• Durable Medical Equipment Cost Compare

Sometimes you may want to contact the Social Security Administration (SSA). You can call SSA at 800-772-1213. It may be helpful to contact SSA about enrollment-related topics, such as enrolling in Medicare Part A and B, or to correct issues with your Medicare Part A and B effective dates. You can also contact Medicare to appeal a higher premium (called IRMAA) or to find the application for Extra Help. You should additionally contact SSA to report a change of address or phone number.  

If you have concerns about the quality of medical care you have received, you should contact your Beneficiary and Family Centered Care—Quality Improvement Organization (BFCC-QIO). You can find your BFCC-QIO by visiting www.qioprogram.org. A staff member can help you access and complete the quality-of-care complaint form. Examples of quality of care complaints might be if you received unnecessary or inappropriate surgery or treatment, or if you experienced prescription drug errors.  

Now, who should you contact if you think you’re experiencing not just a coverage issue, but perhaps Medicare fraud, errors, or abuse? Call your local Senior Medicare Patrol (SMP). SMPs empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report healthcare fraud, errors, and abuse. You can find your SMP by calling 877-808-2468.

If you need more assistance and individualized counseling, you can reach out to your local State Health Insurance Assistance Program (SHIP). The trained staff there can provide unbiased, knowledgeable counseling on your Medicare coverage. To contact your SHIP, visit www.shiphelp.org or call 877-839-2675. 

Lastly, if you need help Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office at 817-952-3153.

When Medicare issues come up, there are a few different places you can contact for help, depending on your problem or question,

Contact the Social Security Administration (SSA) for Medicare Part A and B enrollment and premium issues or update your Medicare address and contact information.

To report a death, contact your local Social Security office or call 1-800-772-1213 (TTY 1-800-325-0778)

You can do much of your Medicare business with Social Security online.

• How to check Medicare eligibility? www.socialsecurity.gov/benefits/medicare
• How to sign up for Hospital Insurance? (Part A) www.socialsecurity.gov/benefits/medicare
• How to sign up for Medical Insurance? (Part B) www.socialsecurity.gov/benefits/medicare
• How to apply for Extra Help with Medicare Prescription drug coverage? (Part D) www.socialsecurity.gov/benefits/medicare/prescriptionhelp
• How to appeal an income-related monthly adjustment amount decision? (For people who pay a higher Part B or D premium, if their income is over a certain amount.) www.socialsecurity.gov/benefits/disability/appeal.html
• How to request a replacement Medicare card online? www.socialsecurity.gov/myaccount
• If I already get benefits or have Medicare, how do I report a change of address or phone number? www.socialsecurity.gov/myaccount
• Where do I find publications about Medicare? www.ssa.gov/pubs/?topic=Medicare or www.medicare.gov/publications

Medicare also offers many online services where you can find out:

• What does Medicare cover? www.medicare.gov/what-medicare-covers
• How can I check the status of Medicare Part A or B claims? www.mymedicare.gov
• Where do I find forms for filing a Medicare appeal or let someone speak with Medicare on my behalf? www.medicare.gov/claims-appeals/how-do-i-file-an-appeal
• What do Medicare health and prescription drug plans in my area cost, and what services do they offer? www.medicare.gov/plan-compare
• Which doctors, health care providers, and suppliers participate in Medicare? www.medicare.gov/forms-help-resources/find-compare-doctors-hospitals-other-providers

Go to Medicare’s website, www.medicare.gov, or call 1-800-MEDICARE for most other matters.

For example, contact Medicare to check the status of your Part A (hospital) or B (medical) claims, to get assistance comparing Medicare Advantage (managed care) or Part D (prescription drug plans), or to file a complaint against your Medicare Advantage or Part D plan. You can contact either SSA or Medicare to request a replacement Medicare card.

If you have a Medicare Advantage or Part D plan, you should contact your plan directly to learn about its coverage rules and costs, which may differ from those of original Medicare. Also contact your Advantage or Part D plan to appeal their coverage decision or to file a grievance, which is a formal complaint, usually about poor customer service or administrative errors.

If you need help Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office at 817-952-3153.

Your Medicare card is proof of your Medicare insurance. If your Medicare card was lost, stolen, or destroyed, you can request a replacement with your personal my Social Security account.

If you don’t already have an account, you can create one online. Go to Sign In or Create an Account.

Once you are logged in to your account, select the “Replacement Documents” tab. Then select “Mail my replacement Medicare card.”

Your Medicare card will arrive in the mail in about 30 days at the address on file with Social Security so be sure to make sure your mailing address is correct before completing the request.

If you need to know your new Medicare number now, you have some options. In your personal my Social Security account, you can get your Benefit Verification Letter, which includes your Medicare number. You can also visit Medicare.gov and sign in to see your Medicare number and print an official copy of your card. If you don’t have a Medicare.gov account, go to Medicare.gov and select “Log In/Create Account”. Then, follow the instructions.

If you can’t or prefer not to use the online service, you can call 1-800-MEDICARE (1-800-633-4227 TTY 1-877-486-2048).

If you need help with this process Ashford Insurance can assist you. Contact your agent or call the office today at 817-952-3153.

If your Medicare Advantage card is lost or stolen, you can replace it by calling your plans customer service line.  With some plans, you may also order or print a replacement card by logging into your insurance carrier’s consumer portal. 

If you need help with this process Ashford Insurance can assist you. Contact your agent or call the office today at 817-952-3153.

Just because you receive a bill from a doctor, hospital or vendor, does not mean that you owe it. There are a lot of reasons you may have received the bill. It could be just a courtesy bill for your records. Sometimes mistakes happen during billing and they get coded incorrectly. Sometimes the office may not have your updated insurance information.

What we recommend doing first is wait until you get your explanation of benefits from your insurance plan to see what it says you owe. If you find discrepancies then contact your doctors’ billing department and make sure they have the correct insurance information and have submitted it correctly.

If that is all good you should contact your plans customer service line and talk to someone in claims by calling the number on the back of your plan member ID card (health insurance card). 

If the issue is still not resolved, you can appeal the claim by contacting your plan’s customer service and then following your plans appeals process.

If you need help with this process Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office today at 817-952-3153.

If you are receiving Social Security benefits before turning 65, you should automatically receive notification of your enrollment in Medicare shortly before your 65th birthday or your 25th month of disability. Other individuals must apply by calling or visiting their Social Security office to receive Medicare. If you are not yet receiving Social Security or if you have not received a Medicare enrollment notice, you should contact the nearest Social Security office for information. Applications for Medicare can be made during a seven-month period beginning three months prior to the month of your 65th birthday.

It is best to apply during the three months prior to the month of your 65th birthday. If an application is made during that time, your coverage will begin on the first day of your birth month. Applying later will delay the start of your benefits. You may also apply for Medicare during the General Enrollment Period from January 1 through March 31 every year after your 65th birthday. Your coverage then starts July 1 of the year you signed up and you will pay a 10 percent surcharge on the Part B premium for every 12 months you were eligible but not enrolled. If you have limited income and resources, your state may help you pay for Part A, and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.

If you continue to work after age 65 or your spouse is working and you are covered by an employer group health plan (EGHP), you may want to delay enrollment in Part B of Medicare. Enrolling in Medicare Part B will trigger your open enrollment for Medicare supplement insurance at a time when you do not need supplemental coverage. The penalty for late enrollment in Part B does not apply if you are covered by an EGHP because of your or your spouse’s current employment.

If you do work after age 65, you may apply for Medicare Part B at any time prior to retirement, but you must apply no later than eight months (the Special Enrollment Period) after your formal retirement in order to avoid paying a premium penalty. Even if your employer offers a retirement health plan, you will want to sign up for Medicare Part A and probably for Medicare Part B when you retire. Most retirement plans assume you are covered under Medicare and will not pay for services that Medicare would have covered. Veterans may be eligible for special medical programs. However, eligibility and benefits are very restrictive and are subject to change. The Department of Veterans Affairs advises veterans to apply for both Parts A and B of Medicare to ensure adequate medical coverage.

If you have delayed your Medicare Part B have your employer fill out a CMS L564 Request For Employment Information form for you to submit with your Part B application CMS 40B Application For Enrollment In Medicare Part B.

If you need help applying for Medicare Ashford Insurance Agents can assist you. Call today at 817-952-3153.

At some point, you may need to change your Primary Care Physician. Doctors retire, move offices, stop accepting your plan, etc. So, you will need a way to get assigned a new doctor and get a new plan member ID card (health insurance card).

One way to do this is simply by calling the number on the back of your plan member ID card (health insurance card). A customer service representative can look up a new doctor in your service area and confirm if they are taking new patients and assign you to that doctor. Then they can send you out a new plan ID card.

You can also lookup doctors that take your plan yourself. Most plans have a provider lookup page on their website just for this purpose. Once you decide on a doctor and confirmed they are taking new patients you can call the number on the back of your plan member ID card (health insurance card) as per above.

A good source for doctor ideas can come from asking friends, family, and your Medicare Agent. Then you can look them up to see if they take your plan and are accepting new patients as above.

Lastly, if you need help with this process Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office today at 817-952-3153.

The need may arise to look up what the cost of a new prescription will be. You can look up the cost of a particular drug in several ways.

Firstly, you can look up a particular drug on your plans Formulary located in the Enrollment Guide your Medicare Agent left with or emailed to you.

Secondly, you can look up a drug on your plans prescription lookup page. 

Lastly, if you need help with this process Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office today at 817-952-3153.

The easiest way to learn about changes to your plan is to read the Explanation Of Changes (EOC) that your plan will mail to you in early October of each year. Your Agent can also go over the changes starting in October 1^st each year. You could even attend one of our Medicare Neighborhood meetings to learn about your plan.

If you have questions Ashford Insurance can assist you. Contact your Medicare Insurance Agent directly or call the office today at 817-952-3153.

If the cost of your prescriptions suddenly go up you may have entered into the Medicare prescription drug coverage gap or “donut hole”. This is the stage where you typically pay 25% of the plan’s cost for brand-name drugs and 25% of the plan’s cost for generic drugs in 2021.

You should be getting monthly or quarterly statements throughout the year from your plan. These statements will show how much you and your plan has spent on your prescription drugs, where you are in the Medicare prescription drug stages, and how much more until the next stage.

Remember, it is about what you and your plan spend on your prescriptions that adds up to the total to move to the coverage gap stage from the initial stage.

If you have questions Ashford Insurance can assist you. Contact your Medicare Insurance Agent directly or call the office today at 817-952-3153.

You may find it necessary to get help paying for prescriptions even after enrolling in Medicare drug coverage (Part D). For example, you may reach the annual spending limit and enter what is called the coverage gap. Here are 6 tips to consider if you think you might need to get help with the costs of prescription drug coverage.

1. Consider switching to generics or other lower-cost drugs.

There may be generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now. Talk to your doctor to find out if these are an option for you. You might also be able to lower prescription costs by using mail-order pharmacies.

2. Choose a Medicare drug plan that offers additional coverage during the gap.

There are plans that offer additional coverage during the Medicare drug coverage gap, like for generic drugs. However, plans with additional gap coverage to help pay for prescriptions may charge a higher monthly premium.

Check with the drug plan first to see if your drugs would be covered during the gap. Find health & drug plans.

3. Pharmaceutical Assistance Programs. 

Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare drug coverage (Part D). Find out whether there’s a Pharmaceutical Assistance Program that can lower prescription costs for the drugs you take.

4. State Pharmaceutical Assistance Programs.

Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs. Find out if your state has a State Pharmaceutical Assistance Program.

5. Apply for Extra Help.

Medicare and Social Security have a program called Extra Help—a way for people with limited income and resources to get help with prescription costs. If you qualify for Extra Help, you could pay no more than:

• $3.70 for each generic covered drug
• $9.20 for each brand-name covered drug

6. Explore national and community-based charitable programs like these that help pay for medications:  

• National Patient Advocate Foundation
• National Organization for Rare Disorders
• Benefits checkup

If you have questions or need help applying for Medicaid Ashford Insurance can assist you. Contact your Medicare Insurance Agent directly or call the office today at 817-952-3153.

This usually happens when someone has delayed taking their Medicare Part B. We recommend having your employer file out a CMS L564 Request For Employment Information form and sending it in with your Medicare Part  B application.

If you didn’t get Part B when you’re first eligible, your monthly premium may go up 10% for each 12-month period you could’ve had Part B, but didn’t sign up. In most cases, you’ll have to pay this penalty each time you pay your premiums, for as long as you have Part B. And, the penalty increases the longer you go without Part B coverage.

Usually, you don’t pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period. Read more about different situations that may affect when you decide to get Part B. 

When you receive this letter, please do not ignore it. Simply respond by filling out the return form stating you had previous creditable healthcare coverage through your employer. Generally, they do not need much more than that.

If you have questions Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office at 817-952-3153.

The late enrollment penalty is an amount that’s permanently added to your Medicare drug coverage (Part D) premium. You may owe a late enrollment penalty if at any time after your Initial Enrollment Period is over, there’s a period of 63 or more days in a row when you don’t have Medicare drug coverage or other creditable prescription drug coverage . You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.

When you receive this letter, please do not ignore it. Simply respond by filling out the return form stating you had previous creditable prescription drug coverage through your employer or other insurance. Generally, they do not need much more than that.

If you have questions Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office at 817-952-3153.

Yes, you can get a prescription filled while traveling. However, as usual, you may have to pay more if you use a non-preferred pharmacy. Show the pharmacy your id card and transfer your prescription so they can fill it.

Choosing a network pharmacy may help you save on costs. You can find your plans Preferred Pharmacies by looking in the Enrollment Guide your Medicare Agent left with or emailed to you.

Secondly, you can look up a drug on your plan’s prescription lookup page. If you don’t use a participating network pharmacy, you may have to pay the full retail price for your prescriptions.

Alternatively, if you need help with this process Ashford Insurance can assist you. Contact your Medicare insurance Agent directly or call the office at 817-952-3153.

If your Medicare Advantage Plan denies coverage for a health service or item before you have received the service or item, you can appeal to ask your plan to reconsider its decision. Follow the steps below if you feel that the denied health service or item should be covered by your plan. 

• Before you can start your appeal, you will need to get an official written decision from your plan, called a Notice of Denial of Medical Coverage. Sometimes you first learn that your plan will not cover a service or item when you or your doctor calls to confirm coverage before the service is provided. If the plan tells you that the service or item will not be covered, they should also send you a Notice of Denial of Medicare Coverage. You should receive this written denial within 14 days.
  • If you don’t receive a Notice of Denial of Medicare Coverage within two weeks (or 28 days if your plan extended its decision deadline), you can file an appeal without it. Start your appeal by sending a letter to your plan explaining that it has been two weeks since you initially requested an item or service, and you have not received a denial notice. If possible, include a doctor’s letter of support. You may also want to file a grievance.

• You can request a fast (expedited) appeal if you or your doctor feel that your health could be seriously harmed by waiting the standard time for an appeal decision. If your plan approves your request to expedite, it should issue a decision within 72 hours. For this and the following levels of appeal, your doctor can ask that the plan follow the expedited timeline.
  • In some cases, your plan can extend its decision deadline up to 14 days. You should be notified if this happens.

• Start your appeal by following the instructions on the Notice of Denial of Medical Coverage. Make sure to file your appeal within 60 days of the date on this notice. You will need to send a letter to your plan explaining why you need the service or item. You may also want to ask your doctor to write a letter of support, explaining why you need care and addressing the plan’s reason for denial. Your plan should make a decision within 30 days. If you file an expedited appeal, your plan should make a decision within 72 hours.
  • If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension.

• If the appeal is successful, your service or item will be covered. If your appeal is denied, you should receive a written denial notice. Your plan should also automatically forward your appeal to the next level, the Independent Review Entity (IRE). There are several further steps in the appeals process that you may follow if your appeal continues to be denied.

Remember to keep good records of all your communications throughout the appeals process. You should submit all requests in writing, and keep fax transmission reports, mail information by certified mail, or return receipts. Write down the details of any phone calls you make related to your case, including what you discussed, who you spoke to, and the date and time of the call.

If you need assistance understanding the coverage rules surrounding a health service or item, or help to complete your appeal, you can contact your State Health Insurance Assistance Program (SHIP) for assistance by calling 877-839-2675.

Feel free to contact Ashford Insurance for advice or tips. Call your Medicare insurance  Agent directly or the office at 817-952-3153.

Be on the alert for Medicare phone scammers. These scammers may say they’re calling on behalf of Medicare, an insurance company, or even a health care provider.

They may offer a free visit or a piece of medical equipment. They may say they want to update your information or help you take full advantage of your benefits. They may say there’s a problem with your account. Medicare scammers will also use fake faxes requesting information or posing as a retail pharmacy to refill prescriptions.

But what they actually want is access to your personal information in order to commit identity theft – so don’t give it to them.

Unsolicited Calls Are a Sign of a Scam

Health care providers or insurance representatives do not make unsolicited calls asking for your Medicare ID number, Social Security number, or other personal information.

You can ask questions to verify if this caller is actually who they say they are. For example, if they say they are calling from your health care provider, ask a question like: can you verify that this is my health care provider by telling me information about my latest visit?

Likewise, the Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration will not call you to update your information or ask you to disclose financial information in order to get a new card.

How to Avoid the Scam Threat

Unfortunately, scams like this are all too common. When they call you, protect your identity by following these tips:

• Never give out any personal information, including your Medicare or Social Security number.
• Never give your bank information, account number, or credit card number.
• Don’t continue the conversation – just hang up.
• Don’t trust caller ID. It may be a spoofed number and the scammer can make it appear as if the call is coming from someplace locally.
• If you did give out your Medicare number, report it to Medicare and watch your statements for any unauthorized usage of your Medicare number.
• If your Social Security number is compromised, the agencies listed below can provide guidance on steps to take to deter any identity theft.
• Remember to write down any information about the scam call if you intend to report it: the time of the call, the number, and the scripting, including what information about you they had already and what information they wanted you to give them. 

You can use the phone numbers below to report a scam.

• Centers for Medicare and Medicaid Services: 1-800-MEDICARE
• Social Security Administration: 800-772-1213
• If you’re in a Medicare Advantage Plan, call the Medicare Drug Integrity Contractor (MEDIC) at 1-877-7SAFERX (1-877-772-3379).

Have this information before you report fraud:

• Your name and Medicare Number.
• The provider’s name and any identifying information you may have.
• The service or item you’re questioning and when it was supposedly given or delivered.
• The payment amount approved and paid by Medicare.
• The date on your Medicare Summary Notice or claim.