Getting the Right Authority to Act
If you're helping someone manage their health coverage, you likely need documented authority. But there isn't just one kind. Each type serves a different purpose. None of them gives you all the powers you might assume. Here's what each one does and doesn't let you do:
| Tool | What It Lets You Do | How to Set It Up |
|---|---|---|
| Plan's Authorized Representative Form | You can call the health plan. You can ask questions about their coverage, claims, and appeals. You can usually receive notices and submit appeals for them. | Contact the insurance plan directly. Each plan has its own form. Ask for it by phone or download it from their website. The person needs to sign it or give verbal permission. |
| Medicare Authorization to Disclose (1-800-MEDICARE) | You can call Medicare to talk about their account. You can ask questions about their benefits. You can get account information sent to you. | Call 1-800-MEDICARE or work with a Medicare insurance agent. They sign a form to let Medicare share information with you. |
| Power of Attorney (POA) | You can handle their financial and legal decisions. You can pay medical bills, manage savings, and sign documents. What you can do depends on what the legal document says (general or limited POA). | Prepare with a qualified attorney. Cost and requirements vary by state (typically $300–800). The person needs to sign it and, in some states, get it notarized. |
| Social Security Representative Payee | You can receive and manage their Social Security benefits. You collect checks and pay bills if they can't do it themselves. | Apply through the Social Security Administration (SSA). You need to prove they cannot manage benefits themselves. See SSA.gov or call 1-800-772-1213. |
| Healthcare Power of Attorney / Healthcare Proxy | You can make medical decisions for them if they can't. You can choose treatments, hospitals, and end-of-life care. This does NOT let you manage insurance paperwork or handle benefits. | Prepare with an attorney or use a state-specific form (often free from your state health department). They need to sign it and, in some states, get it notarized. |
The key insight: A power of attorney doesn't automatically give you power with Medicare or a health plan. A healthcare proxy doesn't manage insurance. You may need more than one document, depending on what you need to do.
Talking to Medicare and Plans on Someone's Behalf
Here's why plans and Medicare won't just give you information: HIPAA (a federal privacy law) prevents them from sharing health or benefit information with anyone — even family members — without written or verbal permission from that person. It's frustrating when you're trying to help, but it protects their privacy.
How to get permission:
- Ask the person (if they're able) to call the plan or Medicare themselves. They can give you permission on the phone. Then you can call back on their behalf.
- Have the person sign the plan's Authorized Representative form or Medicare's authorization form. Send it in before you call.
- If the person can't communicate, a healthcare proxy or power of attorney might work. But verify with the plan or Medicare which documents they accept — it varies.
Organizing the Essentials
The faster you organize information, the faster you can help. Keep these documents and details in one place:
- Insurance cards (front and back, both Medicare and any private plan or Medicaid card)
- Plan name, member ID, and Group number (often on the card)
- Phone numbers: the plan, Medicare, the primary care doctor, pharmacy
- List of all current doctors and specialists, with contact info and specialties
- List of all medications (names, doses, pharmacy)
- Recent prescription and medical bills (for appeals or claims questions)
- Dates of key deadlines: Open Enrollment, appeal deadlines, denial letters
- A copy of any Authorized Representative forms or POA documents you've filed
- Account logins for pharmacy or plan portals (stored securely, NOT on a sticky note)
Helping with Enrollment and Appeals
Two key moments when caregivers step in: choosing a plan and challenging a denial.
- Enrollment: See Enrollment & Deadlines to learn when people can change plans. If they're new to Medicare or Medicaid, or their life changed (income, location, job loss), they may qualify for a Special Enrollment Period outside Open Enrollment.
- Choosing a plan: Read Choosing Coverage to compare plans. Read Understanding Your Costs to learn how premiums (monthly costs), deductibles (the amount you pay before coverage starts), and out-of-pocket limits work.
- Appeals: If a plan denies a claim or Medicare denies a service, you can appeal. See Your Rights for the appeal process and deadlines. Many denials can be overturned with the right information.
Managing Dual-Eligible Coverage
Some people qualify for both Medicare and Medicaid. This is called "dual-eligible." It's common among people with very low income or high long-term care needs.
- How it works: Medicare is federal. Medicaid is state and federal. They overlap and sometimes conflict. Generally, Medicare pays first. Then Medicaid may cover gaps.
- Rules vary by state: What Medicaid covers, income limits, and how the two work together differ by state.
- Where to learn more: Coverage Basics for the big picture. State Directory to find your state's Medicaid office and rules.
Support for the Caregiver
Being a caregiver is a job. You don't have to do it alone. The Eldercare Locator is a free national service that connects you with local support:
- eldercare.acl.gov or call 1-800-677-1116
- They can refer you to Area Agencies on Aging in your area. They offer counseling, respite care (temporary break from caregiving), meal programs, transportation, and help navigating benefits.
- Also see Getting Help Paying for financial assistance programs for the person you're caring for.
Long-Term Care: What Medicare and Medicaid Actually Cover
If the person needs nursing home, assisted living, or home care, you need to know what Medicare and Medicaid cover:
- Medicare's role: Very limited. Medicare covers up to 100 days of skilled nursing facility care (medical care in a nursing home) after a qualifying hospital stay. It does NOT cover custodial care (personal care). Most long-term care is not covered by Medicare.
- Medicaid's role: Medicaid does cover long-term care (nursing home, assisted living, some home care). But only for people with very low income and limited assets. Rules vary by state.
- Reality: Many families pay out-of-pocket for long-term care. Or they explore Medicaid planning with an elder-law attorney.
- Official resources: Medicare.gov and Medicaid.gov have more detail. Talk to their care team or a professional advisor for your specific situation.
Common Questions
Can I call Medicare or the health plan about my mom's coverage without her permission?
No. HIPAA privacy law prevents plans and Medicare from sharing health or benefit information with anyone without permission. Your mom needs to either call first and give you permission, or sign an Authorized Representative form that you send in. After that, you can call on her behalf.
Does a power of attorney let me choose my spouse's health plan?
A general power of attorney may give you authority to make healthcare decisions, but it depends on what the document says. A healthcare power of attorney or healthcare proxy is specifically designed for medical decisions. But even with POA, you need to get the plan to authorize you separately (using the plan's Authorized Representative form). POA and plan authorization are two different things.
What happens to their coverage if they move or need to enter a nursing home?
It depends on where they move. If they move to a different state, their Medicaid may change (each state runs its own program). If they move within the state, their Medicare generally stays the same. But their Medicaid may change. If they enter a nursing home, Medicare stays the same. But they may qualify for Medicaid even if they didn't before (nursing-home Medicaid has different asset rules in many states). Talk to the nursing home's social worker and your state Medicaid office before a move.