What to Do When Your Medicare Plan Isn't Working: A Hampton Roads Guide

What to Do When Your Medicare Plan Isn't Working: A Hampton Roads Guide

You did your research, chose what seemed like the best Medicare plan, and now you're discovering your Medicare plan isn't working for your needs. Maybe your doctor isn't in the network, your medications aren't covered, or the costs are higher than expected. You're not alone – and you're not stuck.

After helping Virginia Beach, Norfolk, and Chesapeake residents resolve Medicare plan problems for over 10 years, I can tell you that most plan issues can be solved. The key is understanding your options and knowing when you can make changes.

Let me walk you through the most common Medicare plan problems and exactly what you can do to fix them.

Common Medicare Plan Problems Hampton Roads Residents Face

Problem 1: Your Doctor Isn't in the Network This is one of the most frustrating discoveries. You chose a Medicare Advantage plan thinking you could keep your longtime physician, only to find out they're not covered or have been dropped from the network.

Problem 2: Prescription Costs Are Higher Than Expected Your medications might not be on the plan's formulary, they might be in a higher tier than anticipated, or the plan might require prior authorization or step therapy before covering your prescriptions.

Problem 3: Unexpected Out-of-Pocket Costs Despite researching the plan, you're facing higher copays, deductibles, or coinsurance than you expected, especially for specialist visits or procedures.

Problem 4: Limited Access to Specialists Your plan requires referrals for specialist care, or the specialists you need aren't in the plan's network, forcing you to travel farther or pay more for care.

Problem 5: Customer Service Issues You can't get help when you need it, claims are being denied incorrectly, or the plan's customer service is unresponsive to your concerns.

Problem 6: Geographic Coverage Limitations You spend time outside Virginia Beach or travel frequently, and your Medicare Advantage plan doesn't provide adequate coverage outside the local area.

Immediate Steps to Take When Your Plan Isn't Working

Step 1: Document Everything Keep detailed records of all problems you're experiencing, including dates, times, phone calls made, and any correspondence with your plan. This documentation will be valuable if you need to file appeals or complaints.

Step 2: Understand Your Current Plan's Rules Before assuming you can't get the care you need, thoroughly understand your plan's requirements. There is a member services number on the back of the card, for your use to contact the company directly.  You may look up your plan in the back of the Medicare and You for the current year. 

Step 3: Use Your Plan's Appeals Process If your plan denies coverage for something you believe should be covered, you have the right to appeal. The appeals process can sometimes resolve coverage issues without needing to change plans.

Step 4: Contact Your Plan's Customer Service Before giving up on your current plan, contact your local agent or Retha Rish Insurance agency for more information.

When You Can Change Your Medicare Plan

During Annual Open Enrollment (October 15 - December 7): This is your primary opportunity each year to change Medicare plans. You can:

●       Switch from Original Medicare to Medicare Advantage or vice versa

●       Change from one Medicare Advantage plan to another

●       Add, drop, or change Part D prescription drug plans

●       Add or drop Medicare Supplement insurance

During Medicare Advantage Open Enrollment (January 1 - March 31): If you're enrolled in a Medicare Advantage plan, you get a second chance to:

●       Switch to a different Medicare Advantage plan

●       Drop your Medicare Advantage plan and return to Original Medicare

●       Add a Part D plan if you return to Original Medicare

Special Enrollment Periods: Certain qualifying events allow you to change plans outside of standard enrollment periods:

●       Moving to a new area

●       Losing other health coverage

●       Your plan stops offering coverage in your area

●       You qualify for or lose Medicaid eligibility

●       You move into or out of a long-term care facility

Specific Solutions for Common Problems

If Your Doctor Isn't in Network:

●       Check if your doctor accepts Medicare and consider switching to Original Medicare with a Medicare Supplement plan

●       Look for Medicare Advantage plans in your area that include your doctor

●       Ask your doctor if they're planning to join any Medicare plan networks

If Your Medications Aren't Covered:

●       Work with your doctor to see if there are covered alternatives

●       File an exception request with your plan if no suitable alternatives exist

●       Consider switching to a plan that covers your medications during the next enrollment period

If Costs Are Too High:

●       Review whether a Medicare Supplement plan might provide more predictable costs

●       Look for Medicare Advantage plans with lower out-of-pocket maximums

●       Consider plans with different cost structures (lower premiums but higher copays, or vice versa)

If You Need More Provider Choice:

●       Consider switching to Original Medicare with a Medicare Supplement plan, which allows you to see any Medicare-accepting provider

●       Look for Medicare Advantage plans with larger provider networks

●       Consider whether paying out-of-network costs might be worthwhile for specific specialists

The Role of Medicare Supplement Plans in Solving Problems

Many Medicare plan problems stem from the limitations of Medicare Advantage plans. Medicare Supplement insurance can solve several common issues:

Provider Network Freedom: With Original Medicare plus a supplement plan, you can see any doctor who accepts Medicare – no network restrictions.

Predictable Costs: Supplement plans help cover Medicare's deductibles and coinsurance, making your healthcare costs more predictable.

No Referrals Required: You can see specialists directly without needing referrals from a primary care physician.

Geographic Flexibility: Your coverage works anywhere in the United States, perfect for travelers or those who spend time in multiple states.

Questions to Ask When Evaluating Your Options

1. What specific problems am I experiencing with my current plan?

2. Are these problems likely to continue or get worse?

3. Can these issues be resolved within my current plan through appeals or proper procedures?

4. What are my alternatives during the next enrollment period?

5. Would I be better served by Original Medicare plus supplements rather than Medicare Advantage?

6. What are the total costs (premiums plus out-of-pocket) of different plan options?

   
   

How I Help Hampton Roads Residents Solve Medicare Plan Problems

As your local Medicare broker, I provide solutions tailored to your specific situation:

Problem Analysis: I help you identify exactly what's not working with your current plan and whether the issues can be resolved.

Options Review: I show you all available alternatives and explain how each option would address your specific problems.

Timing Guidance: I help you understand when you can make changes and what steps to take immediately versus waiting for enrollment periods.

Transition Planning: If you decide to change plans, I guide you through the process to ensure smooth transitions with no coverage gaps.

Don't Suffer with a Plan That Doesn't Work

Many Virginia Beach seniors think they're stuck with Medicare plans that don't meet their needs, but that's rarely the case. While you can't change plans anytime you want, there are usually solutions available if you know your options and timing.

The key is not to wait until problems become crises. If you're experiencing issues with your current Medicare coverage, start exploring your options now so you're prepared to make changes during the next enrollment period.

Call Retha Rish Insurance Agency at 757-692-8388 or email rrish@asb.insure to discuss your Medicare plan problems and explore your options.

Don't struggle with Medicare coverage that doesn't work for you. There are solutions available, and I'm here to help you find the right path forward based on your specific needs and circumstances.