How Do I…?

A grievance is a complaint about your plan's service, billing, or treatment — not about a coverage decision. For example, if your provider couldn't see you on time or member services was rude, that's a grievance.

An appeal is a formal request to overturn a plan's decision to deny a service or a claim. You appeal when the plan said "no" and you disagree.

Both have deadlines and processes. Your EOB or denial letter tells you which one applies and how to file.

Appeal deadlines vary by program. Medicare members usually have 60 days to file an appeal after receiving a denial. Medicaid deadlines vary by state but are often 30–60 days. ACA Marketplace plans typically follow federal rules (60–180 days, depending on the issue).

Your denial letter states your specific deadline. Don't miss it — once the deadline passes, you lose your appeal right (with few exceptions). If you're unsure, contact your plan or call your SHIP right away.

You were probably under "observation status." You're an inpatient only after a doctor formally admits you; until then, even an overnight stay is outpatient care billed to Part B, and it doesn't count toward the 3-day inpatient stay Medicare requires before covering a skilled nursing facility. See Hospital Observation Status vs. Inpatient Admission.

Mostly no. Medicare covers up to 100 days of skilled nursing facility care after a qualifying hospital stay, but it does not cover long-term custodial care (ongoing help with daily living). Medicaid is the main program that pays for that. See Does Medicare Cover Nursing Home or Long-Term Care?

To get Medicaid long-term care, your assets must be under your state's limit. You may need to spend down first, and the state reviews past transfers — gifts can trigger a penalty period. See Medicaid Spend-Down and Look-Back Rules.

Original Medicare mostly doesn't. Many Medicare Advantage plans add these as extra benefits, and Medicaid may cover some of them in certain states. See Does Medicare Cover Dental, Vision, and Hearing?

Yes, both — and you pay little or nothing for either. Hospice is comfort care at the end of life under Part A; home health is part-time skilled care at home. But Medicare won't pay for 24-hour care or pay family caregivers. See Medicare Hospice and Home Health Benefits.

Appeal — you or your doctor can file within 65 days of the denial notice, and if the plan says no again, the case goes to an independent reviewer automatically. Plans must also give a specific reason for every denial. See Medicare Advantage Prior Authorization: How It Works and What to Do When Denied.

Not when you enroll — the home is usually protected while you're alive. But if Medicaid pays for long-term care after age 55, the state may seek repayment from the estate after death, with important protections for spouses and certain family members. See Medicaid Estate Recovery: Can Medicaid Take My House?

Remember one rule: Medicare will never call to sell you anything or visit your home. Guard your Medicare Number, check your statements, and report anything suspicious to 1-800-MEDICARE or 1-800-HHS-TIPS. See Medicare Scams: How to Spot and Report Them.

Yes, for people who qualify. Starting July 1, 2026, a temporary Medicare program covers certain GLP-1 drugs for a flat $50 a month if you have Part D drug coverage and meet the health rules. See Does Medicare Cover Weight-Loss Drugs?

They're Medicare's yearly quality scores for Medicare Advantage and Part D drug plans, from 1 star (lowest) to 5 stars (highest). New ratings come out each fall on Medicare.gov's Plan Finder, and a 5-star plan in your area unlocks a special chance to switch. See Medicare Star Ratings: What the Stars Mean.

You can switch during certain windows each year — but getting a Medigap policy afterward is the tricky part. Insurers can turn you down unless you have a guaranteed issue right, like the 12-month trial right, and you must apply within 63 days of your plan ending. See Switching from Medicare Advantage Back to Original Medicare.

Some adults will. A new federal rule requires certain adults ages 19–64 to show 80 hours a month of work or other activities, starting in states no later than January 1, 2027. Many people are exempt — including parents of young children and people who are medically frail. See Medicaid Work Requirements: Who Must Comply, Who Is Exempt.

The temporary extra premium tax credits that started in 2021 have expired, so many people's share of the premium jumped even though their plan barely changed. Updating your income and comparing plans can help. See Why Did My Marketplace Premium Go Up?

Yes. Part B covers counseling, psychotherapy, psychiatric care, and a free yearly depression screening; Part A covers hospital mental health care, and telehealth therapy from home is covered too. See Does Medicare Cover Therapy and Mental Health Care?

Yes. With about 10 years of U.S. work (yours or a spouse's), Part A is premium-free. Without it, green card holders who have lived in the U.S. for 5 continuous years may buy in. See Medicare for Immigrants and Green Card Holders.

Anywhere in the U.S., yes — Original Medicare has no networks. Outside the U.S., usually no, apart from rare exceptions and some Medigap plans' foreign travel emergency benefit. See Does Medicare Cover You When You Travel?

Yes. Permanent kidney failure (ESRD) that needs regular dialysis or a transplant qualifies you for Medicare at any age, if you or a spouse or parent has enough work history. Coverage usually starts in your fourth month of dialysis, and you have to sign up through Social Security. See Medicare for Kidney Failure (ESRD): Dialysis and Transplant at Any Age.

First find out why. If it was missed paperwork, contact your state agency and reapply. If you no longer qualify, you can buy a Marketplace plan through a Special Enrollment Period, with up to 90 days after losing Medicaid or CHIP on HealthCare.gov, and many people get a tax credit. See I Lost Medicaid. What Do I Do Now?

Medicare pays in full for a yearly Wellness visit, but that visit is a prevention-planning conversation, not a physical. A routine physical exam isn't covered, and extra tests or problem visits done the same day carry normal cost-sharing. See Medicare Annual Wellness Visit vs. Annual Physical.

Use your expected income for the coverage year, starting from last year's adjusted gross income and adjusting for changes. If you estimate too low, you repay the extra credit at tax time, and for 2026 and later there's no cap on the repayment. See Estimating Income for Marketplace Subsidies.

Often, yes. Medicaid HCBS waivers pay for help at home for people who qualify financially and need a nursing-home level of care. Many let the person choose a family member as the paid caregiver, with state rules. Waivers cap enrollment, so waiting lists are common. See Medicaid Home Care: HCBS Waivers, Waiting Lists, and Getting Paid as a Family Caregiver.

About 6 months before you apply for Medicare or Social Security. Premium-free Part A can start up to 6 months back from when you sign up, and contributions made in those months count as excess. See HSA Contributions and Medicare: The 6-Month Retroactive Part A Trap.

You can, but it's risky. COBRA isn't coverage from a current job, so it doesn't let you delay Part B. Your 8-month window starts when your job ends whether or not you take COBRA, and missing it means a gap plus a lifetime penalty. See COBRA and Medicare: Why COBRA Doesn't Let You Delay Part B.

Yes. The Medicare Prescription Payment Plan lets you pay $0 at the pharmacy and get a monthly bill from your plan instead. It's free to join and charges no interest, but it doesn't lower your total for the year. See Medicare Prescription Payment Plan: Spreading Drug Costs Into Monthly Payments.

Yes, with rules. Part B covers a ground ambulance when other transport could endanger your health, and you pay 20% after the deductible. ER visits carry a copay per visit plus 20% for the doctor's care. Non-emergency rides need a doctor's written order. See Does Medicare Cover Ambulance Rides and ER Visits?

Each covered insulin product costs you no more than $35 a month under Part B or Part D. Continuous glucose monitors, test strips, and monitors are Part B equipment with 20% coinsurance, and screenings, training, and yearly eye exams are covered too. See Medicare Diabetes Coverage: The $35 Insulin Cap, CGMs, and Supplies.

Ask the plan for a formulary exception, with a statement from your doctor explaining why you need that drug. If the plan says no, you have 65 days to appeal, and a second no goes to an independent reviewer. See My Part D Plan Won't Cover My Drug: Formulary Exceptions and Appeals.

Find your exact end date, then use your Special Enrollment Period: it runs from 60 days before you lose coverage to 60 days after. Your options are your own job's plan, a Marketplace plan, or Medicaid if your income is low. See Turning 26: Leaving a Parent's Health Plan.

A Special Needs Plan (SNP) is a Medicare Advantage plan for one group only: people with both Medicare and Medicaid (D-SNP), people with a serious chronic condition (C-SNP), or people in long-term care (I-SNP). You need Part A and Part B, must live in the plan's area, and must meet the plan's special rule to join and to stay. See Medicare Special Needs Plans (SNPs): D-SNP, C-SNP, and I-SNP Explained.

October 15 through December 7, 2026, with changes starting January 1, 2027. You can join, drop, or switch Medicare Advantage or Part D plans and move between Original Medicare and Medicare Advantage. It's not the window for first signing up for Part A or B. See Medicare Open Enrollment 2027: Dates, What You Can Change, and How to Prepare.

Read it for changes to your premium, copays, drug list, doctors, and out-of-pocket maximum that start January 1. If nothing important changed, you can do nothing and keep your plan. If something did, compare plans and switch between October 15 and December 7. See I Got an Annual Notice of Change (ANOC) Letter. What Do I Do?.

Often, yes. Federal law lets Medicaid pay for treatment of an emergency medical condition, including labor and delivery, for people who meet the state's income and residency rules but not its immigration rules. It covers only the emergency, not ongoing care. See Emergency Medicaid: Hospital Coverage Regardless of Immigration Status.

You get a special window to join another plan or return to Original Medicare, and a short window to buy Medigap. See My Medicare Advantage Plan Is Ending for 2027.

A rule called "hold harmless" protects some people, but not everyone. See The Medicare Hold Harmless Rule.

They might, but the negotiated price is not your copay. Your plan's deductible, copay and the yearly cap still decide your cost. See Medicare Drug Price Negotiation in 2027.

If you are already in a Medicare Advantage plan, you get one change between January 1 and March 31. See The Medicare Advantage Open Enrollment Period.

Part B covers memory checks and a care-planning visit, and may cover certain Alzheimer's drugs if rules are met. See Alzheimer's and Dementia Under Medicare.

Federal Medicaid pays for emergency care, and some states run their own programs. See Coverage for Older Immigrants Who Can't Get Medicare.

Marketplace savings stop once you're eligible for Part A, and the plan doesn't end on its own. See Turning 65 on a Marketplace Plan.

HealthCare.gov lists November 1 as the start, December 15 for a January 1 start, and January 15 as the last day. See Marketplace Open Enrollment 2027.

Ask whether they accept Medicare assignment. Doctors who do take the approved amount as full payment. Non-participating doctors can charge up to 15% more. Opt-out doctors get nothing from Medicare, so you pay the whole bill under a private contract. See Does My Doctor Accept Medicare? Assignment, Excess Charges, and Opt-Out Providers.

Yes. Part B covers cataract surgery with a standard lens, and you pay 20% after the deductible. It also covers one pair of standard-frame glasses or one set of contacts after each surgery. Upgraded lenses and frames cost extra. See Does Medicare Cover Cataract Surgery?.

Federal spousal impoverishment rules protect a share of the couple's savings and, if your own income is low, part of your spouse's income for you. Your home is protected while you live in it, and you can ask for a fair hearing if the amounts aren't enough. See Medicaid Spousal Impoverishment Rules.

Part A covers chemo and radiation as a hospital inpatient. Part B covers them as an outpatient, plus infused drugs and a few pills, at 20% after the deductible. Part D covers most other pills you take at home, with a yearly out-of-pocket cap. See Does Medicare Cover Cancer Treatment?.

Yes. Through December 31, 2027, Part B covers telehealth from anywhere in the U.S., including your home, and by phone only in some cases. You pay the same 20% you would in person. See Does Medicare Cover Telehealth?.

It's a real Medicare Advantage benefit: the plan pays part or all of your Part B premium, so less is deducted from your Social Security payment. It's funded from the same money as dental, vision, and lower copays, so compare the whole plan. See Medicare Part B Giveback: How the Premium Reduction Really Works.

Often, yes. Every state must cover pregnant women, the income limit is higher than for other adults, there's no asset test, and pregnancy care has no copays. Coverage lasts at least 60 days after birth, and 12 months in many states. See Medicaid for Pregnancy.

Yes. Retirement, reduced hours, marriage, divorce, and a spouse's death are life-changing events that let you ask Social Security to use your newer, lower income. File Form SSA-44 online, by mail, or by phone at 1-800-772-1213. See Appealing IRMAA With Form SSA-44.

It depends on your state. Dental is required for everyone on Medicaid under 21, but optional for adults. Most states cover at least emergency dental, and fewer than half cover comprehensive care. See Does Medicaid Cover Dental for Adults?

Often, yes. A current, former, or late spouse's work can qualify you for premium-free Part A. For an ex-spouse, the marriage must have lasted at least 10 years and you must be unmarried now. For a spouse who died, the marriage generally must have lasted 9 months. See Medicare Through a Spouse, Ex-Spouse, or Late Spouse's Work Record.

Partly. Some private Medicare Advantage plans put extra benefits on a prepaid debit card, but Medicare itself doesn't issue one and never calls to sell you anything. The amount depends on the plan, the card is limited to the plan year, and the richest offers often belong to plans only certain people can join. See Medicare Flex Cards: What's Real vs. What the Ads Promise.

Yes. Shingles, RSV, and Tdap shots are covered by Part D with no copay or deductible. Flu, COVID-19, pneumonia, and hepatitis B shots are covered by Part B at no cost if your provider accepts assignment. See Free Vaccines Under Medicare: Shingles, RSV, Flu, and COVID-19.

Yes. Part B covers medically necessary equipment your doctor orders for use in your home, from a supplier enrolled in Medicare. You pay 20% after the Part B deductible. Power wheelchairs need a face-to-face exam and a prescription first. See Does Medicare Cover Wheelchairs, Walkers, and Other Medical Equipment?

You can authorize someone — a family member, caregiver, advocate, or attorney — to handle appeals, speak with your plan, and manage your claims. This person is called your authorized representative or agent.

For a single phone call, you can usually just give verbal permission while you're on the line. For someone to act for you on their own — filing an appeal, managing your claims — your plan will ask for written authorization first. The form is usually on your plan's website or you can call member services to request one. For more on caregivers and authorized representatives, see Caregivers & Representative Payees.

No, it's not a bill. The MSN is the claims statement people with Original Medicare get in the mail. It lists what providers billed, what Medicare paid, and the most you can be billed. Check that every provider, date, and service is real, and appeal any denial within 120 days of getting the notice. See How to Read Your Medicare Summary Notice (MSN).

Only in narrow cases. Part B covers a chiropractor's spinal adjustment for subluxation, but not X-rays or massage from the chiropractor. It covers acupuncture only for chronic low back pain, up to 12 treatments in 90 days, from a qualified doctor or other provider. You pay 20% after the deductible. See Does Medicare Cover Chiropractic Care and Acupuncture?

Yes, and there's no annual dollar limit. Congress repealed the old hard "therapy cap" in 2018; today a documentation threshold just tells your therapist to confirm continued care is still medically necessary. You pay 20% after the Part B deductible. See Does Medicare Cover Physical Therapy?

A screening colonoscopy is free, but it becomes a diagnostic procedure the moment a polyp is found and removed. You then owe 15% coinsurance, with no Part B deductible — a rate that's scheduled to drop to 0% by 2030. See Free Screenings That Can Turn Into a Bill.

All three are Medicare Savings Programs that help pay Medicare costs. QMB pays the most — Part B premiums plus deductibles, coinsurance, and copayments, and providers can't bill you for the difference. SLMB and QI pay only your Part B premium. See Medicare Savings Programs: QMB, SLMB, and QI Explained.

Your coverage can end even if you still qualify — called a procedural termination. Contact your state right away: federal rules give you a 90-day reconsideration window to get reviewed again without a new application. See Medicaid Renewal & Redetermination.

Yes. Under Section 1557, any provider that takes Medicare or Medicaid payment must give you a free, qualified interpreter — not a bilingual staffer and not your own child. See Your Right to a Free Medical Interpreter.

Medicare is federal insurance mainly for people 65+ or with certain disabilities, run the same way nationwide. Medicaid is a joint federal-state program for people with limited income, and its rules vary by state. Some people qualify for both. See Medicare vs. Medicaid: What's the Difference?