What Is A Medicare Advocate?
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 and Medicare Advocates
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
Who are Medicare Advocates?
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.
Medicare contacts and self-help toolkits
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.
About Medicare
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.
What are the different parts of Medicare?
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.
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.
Summary
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.
The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Health Line
7 hours ago
- Health Line
Medicare Coverage of Xiidra
Medicare may cover Xiidra (lifitegrast ophthalmic solution) if you have a plan with prescription drug coverage, such as a Part D plan or a Medicare Advantage (Part C) plan. Xiidra is a brand-name drug that doctors may prescribe to treat the symptoms of dry eye disease. Medicare and Xiidra Xiidra belongs to a group of drugs called a lymphocyte function-associated antigen-1 (LFA-1) antagonist. The drug is approved by the Food and Drug Administration (FDA) to treat the signs and symptoms of dry eye disease. To receive coverage for Xiidra, you need to have a Medicare prescription drug plan. If you have Original Medicare (parts A and B), you can enroll in a stand-alone Part D plan to cover your medications. If you have a Medicare Advantage plan, you likely have prescription drug coverage as part of your plan. However, not all Medicare Advantage plans include drug benefits. Private insurance companies offer Medicare drug plans, and their lists of covered drugs differ. Your plan will cover Xiidra if it's included in the plan's formulary. More than half of Medicare drug plans cover Xiidra. Review your plan's documentation or contact a representative to learn whether it covers Xiidra. If it does not, it may cover an alternative medication for dry eye disease. The Centers for Medicare & Medicaid Services (CMS) offers a coverage finder tool to allow users to find plans in their area that include coverage for Xiidra. Xiidra cost with Medicare The amount you pay for Xiidra will depend on a few factors. These include your location, your plan, and the drug's tier. Medicare prescription drug plans group covered drugs into cost tiers. Xiidra is typically a higher tier drug, with no generic version. The amount you pay for Xiidra will also depend on what stage of coverage you are in. In 2025, most Part D plans have three stages of coverage. Beneficiaries will have different out-of-pocket expenses depending on the stage: Deductible stage: If your plan has a deductible, you'll pay the full cost of the medication until you reach your deductible amount. In 2025, the maximum deductible amount for a Part D plan is $590. Initial coverage stage: After meeting your deductible, you'll pay a 25% coinsurance on the cost of covered medications until your out-of-pocket costs reach $2,000. Catastrophic stage: Once you've spent $2,000 in a calendar year, you'll pay no more for covered medications. If you qualify for cost assistance through the Extra Help program, your costs will be lower.
Health Line
7 hours ago
- Health Line
Medicare Coverage of Revlimid
Medicare may cover Revlimid (lenalidomide) if you have a plan with prescription drug coverage, such as a Part D plan or a Medicare Advantage (Part C) plan. Revlimid is a brand-name drug that doctors may prescribe to treat conditions including multiple myeloma and mantle cell lymphoma in certain adults. Medicare and Revlimid Revlimid is a type of drug called a thalidomide analogue. The drug is approved by the Food and Drug Administration (FDA) to treat the following conditions: myelodysplastic syndromes multiple myeloma marginal zone lymphoma follicular lymphoma mantle cell lymphoma To receive coverage for Revlimid, you must have a Medicare prescription drug plan. If you have Original Medicare (parts A and B), you can enroll in a stand-alone Part D plan to cover your medications. If you have a Medicare Advantage plan, it might cover prescription drugs. Not all Medicare Advantage plans include drug benefits. Private insurance companies offer Medicare drug plans, and their lists of covered drugs differ. Your plan will cover Revlimid if it's listed in their formulary. Most Medicare drug plans cover Revlimid. Review your plan's documentation or contact a representative to learn whether it covers Revlimid. If it does not, it may cover an alternative medication. The Centers for Medicare & Medicaid Services (CMS) offers a coverage finder tool to allow users to find plans in their area that include coverage for Revlimid. Revlimid cost with Medicare The amount you pay for Revlimid will depend on a few factors, including your location, your plan, and the drug's tier. Medicare prescription drug plans group covered drugs into cost tiers. Revlimid is typically a higher-tier drug, although it has generic version. According to Revlimid's manufacturer, the list price for the drug is $18,723 per 28-day cycle. The amount you pay for Revlimid will also depend on what stage of coverage you are in. In 2025, most Part D plans have three stages of coverage. Beneficiaries will have different out-of-pocket expenses depending on the stage: Deductible stage: If your plan has a deductible, you'll pay the full cost of the medication until you reach your deductible amount. In 2025, the maximum deductible amount for a Part D plan is $590. Initial coverage stage: After meeting your deductible, you'll pay a 25% coinsurance on the cost of covered medications until your out-of-pocket costs reach $2,000. Catastrophic stage: Once you've spent $2,000 in a calendar year, you'll pay no more for covered medications.
Health Line
7 hours ago
- Health Line
Can You Lose Medicare Coverage?
Medicare coverage is a lifelong benefit for individuals who meet eligibility criteria. However, there are certain situations where a person may have their coverage canceled. To be eligible for Medicare, the federal health insurance program for older adults in the United States, you need to be 65 years of age or older. If you're younger than 65 years old, you may qualify for Medicare if you: have disability and collect Social Security Disability Insurance have end stage renal disease (ESRD) have amyotrophic lateral sclerosis (ALS) If you meet the eligibility requirements for Medicare, you have a right to coverage for the rest of your life. However, it's possible for your coverage to be canceled or discontinued. In this article, we discuss when this might occur and how to reenroll. Why might you lose Medicare coverage? A person may lose their Medicare coverage if they: stop paying their plan's premiums move out of their plan's service area no longer meet the eligibility criteria for the plan Nonpayment of Medicare premiums If you stop paying your monthly premiums, Medicare may terminate your coverage. Individuals enrolled in Original Medicare may have premium payments for Part A and Part B. Generally, there is a grace period of a couple of months after a person stops paying their premium. During this time, you can get caught up on your payments. However, if you don't resume them, Medicare will disenroll you from your coverage. If you're enrolled in a Medicare Advantage (Part C) or Part D plan, you'll also need to continue paying your monthly premiums or risk termination of your coverage. Moving out of a plan's service area If you move your permanent residence outside of your plan's service area, it may affect your coverage. Original Medicare coverage works anywhere in the United States. If you move abroad, you can stay enrolled in Medicare, but it won't cover any healthcare services you receive. Likewise, if you're incarcerated, you can keep your Original Medicare coverage, but it won't be applied toward any of your healthcare costs, which will be covered by the penal institution. Medicare Advantage plans work a bit differently. These plans have regional service areas, and your home address determines which plans you're eligible for. If you move out of your county or state, it's possible that you'll no longer be in your plan's service area. If you have a Medicare Advantage plan and become incarcerated, the plan will consider you outside its service area and disenroll you. If this happens, you may be disenrolled from the plan. No longer meeting eligibility criteria If you're eligible for Social Security Disability Insurance (SSDI), you're also eligible for Medicare. Eligibility involves having a condition that: prevents you from working at the substantial gainful activity (SGA) level prevents you from working at the same level you once did is expected to last for at least a year or be fatal If you no longer meet the eligibility requirements for disability with the Social Security Administration, and you're younger than 65 years old, your Medicare coverage may be discontinued. However, if you have a qualifying disability but end up returning to work, you won't automatically lose your Medicare coverage, provided your disability persists. If you qualify for Medicare due to ESRD, your Medicare coverage will end 12 months after you stop receiving dialysis and 36 months after a successful kidney transplant. Depending on why you lost Medicare coverage, you can likely reinstate it. If you are disenrolled from Original Medicare, a Medicare Advantage plan, or a Part D plan due to nonpayment of the plan's premium, you'll have to wait until the Medicare open enrollment period to sign back up. However, if you go without Medicare coverage for an extended time, you may be responsible for paying late enrollment penalties after you do enroll. People who lost coverage due to leaving their plan's service area may be able to avoid late enrollment penalties by qualifying for a special enrollment period (SEP). SEPs allow people to enroll in coverage outside of traditional enrollment periods. If you have questions about reenrolling in Medicare after losing coverage, consider speaking with a Medicare representative about your situation or contacting your local State Health Insurance Assistance Program (SHIP). The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
