Knowledge is power! We help you avoid the 10 most common Medicare complaints.
Medicare complaints. Whether it's Medicare enrollment, costs, or coverage, it seems like everyone has them. Most of the time, it comes down to a disconnect between what people expect and how the Medicare program actually works. Here, we describe the most common Medicare complaints and how to resolve them.
Common complaints about Original Medicare
Original Medicare includes Parts A and B. Medicare Part A covers inpatient services such as you'd receive in a hospital or skilled nursing facility. Medicare Part B helps pay for outpatient services, like doctor appointments and lab work. You'll notice neither part includes prescription drug coverage, and that takes us to our first complaint.
Why doesn't Original Medicare cover prescription drugs?
Original Medicare never covered prescriptions beyond what healthcare providers administered in a medical setting, such as injections. The sharp rise in prescription drug costs in the 1990s and early 2000s led to the passage of the Medicare Modernization Act (MMA) in 2003. MMA gave us both Medicare Part D (prescription drug plans) and Medicare Part C (Medicare Advantage plans).
Why wasn't I automatically enrolled in Medicare?
This is one of the more common misconceptions about Medicare. For decades, Medicare enrollment occurred automatically when you turned 65, because that was the same age people began collecting Social Security retirement benefits. And although the Centers for Medicare and Medicaid Services (CMS) manage the Medicare program, you sign up for Medicare through the Social Security Administration (SSA).
Everything changed in 1983, when the Reagan administration passed legislation that raised the full retirement age to 67. This legislation did not take effect until 2003, the same year that MMA passed. It is a gradual increase spanning 22 years, making 2025 the year that 67 becomes the full retirement age.
Medicare eligibility, however, remains age 65 (unless you qualify due to disability or illness). And unless you begin collecting either Railroad Retirement Board (RRB) or Social Security benefits at least 4 months before turning 65, you are not automatically enrolled in Medicare.
I have Medicare Part B, but it isn't covering my durable medical equipment. Why?
Medicare Part B coverage does include durable medical equipment (DME). However, you must meet all of the requirements to get DME coverage. The first of which is that the equipment must be considered medically necessary (meaning a qualified healthcare provider ordered it). In addition, your DME must be for use inside the home. Finally, you must get your durable medical equipment from a provider who accepts assignment AND is enrolled in Medicare.
Why do I pay more for Medicare Part B?
As with most types of health insurance, Medicare has monthly premiums. The standard Medicare Part B premium is $164.90 in 2023. However, high earners usually have to pay a surcharge known as IRMAA, which stands for Income-Related Monthly Adjustment Amount.
Less than 5 percent of Medicare beneficiaries owe the IRMAA surcharge, which effects both your Part B and Part D premiums. To be considered a high earner, your yearly modified adjusted gross income (MAGI) must be over $97,000 (filing singly) or $194,000 (married filing jointly).
This article describes how IRMAA is determined, what you can expect to pay, and how to contest the decision if your income has changed.
I recently made the switch to Medicare, but they still aren't paying my claims. Why?
The most common reason Medicare fails to pay claims when you first enroll is because you had group health insurance through an employer (either yours or your spouse's) when you turned 65. If you retired (or your spouse, if the insurance was through their employer) and nobody informed Medicare, then Medicare does not know it is now your primary insurance. Of course, your benefits administrator is supposed to notify Medicare of the change. But mistakes happen. Your best bet is to call 1-800-MEDICARE.
Another reason Medicare may not pay your claims is that you haven't met your yearly deductibles. The Medicare Part B deductible is $226 in 2023. For Part A, deductibles are per benefit period, which begins the day you're admitted as a hospital inpatient and ends once you go 60 consecutive days without receiving inpatient care. The Medicare Part A deductible in 2023 is $1,600.
To learn more about Medicare deductibles, click here.
Finally, Medicare relies on your healthcare provider to submit a claim for payment. If the provider fails to do so, Medicare doesn't even know there's a claim to pay. If your provider does not accept assignment (i.e. agree to accept the Medicare-approved amount), you have to submit the claim to Medicare yourself. Alternatively, your provider may simply have forgotten to submit the claim, or made an error of some kind. This article explains the Medicare claim process and how to submit a request for reimbursement.
Why doesn't my Medigap plan cover everything?
Medicare Supplement Insurance plans, commonly known as Medigap, help pay a variety of out-of-pocket costs when you have Original Medicare. However, they only pay for services that are covered by Medicare. For example, that means you can't use a Medigap plan to pay for dental care, since dental isn't included with Original Medicare.
It's also important to understand what your Supplement plan covers, since not all Medigap plans offer the same benefits. Our Ultimate Guide to Medicare Supplement Plans helps you compare your options and explains how the program works.
Common complaints about Medicare Advantage
At a minimum, Medicare Advantage (MA) plans must provide the same coverage you get with Original Medicare. Most MA plans also offer additional coverage, though, such as prescription drugs, eyeglasses, and routine dental care.
Advantage plans are provided by private insurance companies, which means benefits and costs can vary widely. And that can lead to a lot of confusion, starting with the following complaint.
Why does my Medicare Advantage plan cost so much?
As with Original Medicare, MA plans use a cost-sharing model that includes deductibles, monthly premiums, and copays or coinsurance. Some plans have extremely low premiums that may hide higher out-of-pocket costs elsewhere.
To truly understand how much your Medicare Advantage plan will cost, you need to look at ALL of those charges. And if it's a Medicare Advantage Prescription Drug plan (MA-PD), you also need to review the drug formulary. If it does not include your prescriptions, or places them on a higher tier, your out-of-pocket costs for prescriptions will be pretty high.
You also need to look at the plan's restrictions, such as the provider network. In addition to your primary doctor, this may include clinics, pharmacies, specialists, DME suppliers, and more. Out-of-network care will ALWAYS cost more with an Advantage plan – especially if you have an HMO.
Finally, don't forget that you're still responsible for the Medicare Part B premium – even if your Advantage plan has a monthly premium. See our article, How to Compare Medicare Advantage Plans, to help find the best plan for your unique needs and budget.
Why do I have to use a provider network with my Medicare Advantage plan?
If you started out with Original Medicare, you probably noticed one major difference from the group health plans you had in the past: No provider network.
Medicare Part C is different, though. Most Advantage plans have a provider network. Although they're mainly associated with HMOs, nearly every type of MA plan uses a network, including PPOs (preferred provider network) and SNPs (special needs plan). It's another method to help contain costs.
Common Medicare Part D complaints
There are two types of Medicare Part D prescription drug plans:
- Standalone Part D plans are for people who have either Original Medicare or a Medicare Advantage plan that doesn't cover prescriptions
- Medicare Advantage Prescription Drug plans
Both are provided by private insurance companies that set their own rates, drug formularies, and other restrictions like tiered pricing.
My prescriptions cost more than they used to. Why?
Medicare Part D plans – either MA-PD or standalone – use tiered pricing. Drugs on the lower tiers cost less than those on the higher tiers. You usually pay between $3 and $20 for prescriptions on the lower tiers, with copays rising along with the tiers.
Generic drugs and preferred name brand medications are generally on the bottom tiers. Non-preferred name brands and specialty drugs are on the higher tiers. To estimate your prescription drug costs, you need to know which tier they're on.
Why am I still paying for prescriptions if the donut hole went away?
This Medicare complaint mostly comes down to people not understanding how Part D pricing works – and has always worked.
There are four phases of Medicare Part D:
1. Deductible Phase
2. Initial Coverage Phase
3. Coverage Gap Phase (also known as the donut hole)
4. Catastrophic Coverage Phase
During the deductible phase, you are responsible for 100 percent of costs until you meet your Part D plan's yearly deductible. Once you meet your deductible, you're responsible for 25 percent of your prescription drug costs until you reach the catastrophic coverage phase.
You leave phase two once you AND your plan spend a combined total of $4,660 (in 2023). You leave phase three once YOU ALONE spend $7,400. After that, your out-of-pocket during the catastrophic coverage phase is minimal.
The confusion arrives because, prior to the Affordable Care Act (ACA) passing, Medicare beneficiaries had to pay 100 percent of their prescription drug costs once they reached the coverage gap. ACA included a provision that protected America's seniors from those rising drug costs.
For more information, please see our article, Medicare Donut Hole.
And to compare Medicare plans in your area, use our Find a Plan tool. Just enter your zip code to get started.
H.R.1 - Medicare Prescription Drug, Improvement, and Modernization Act of 2003
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How to Sign Up for Medicare At Age 65
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