SHINE: Serving the Health Insurance Needs of Everyone

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Written by Lorraine York-Edberg, Western Mass. Regional SHINE Program Director

Published: January 17, 2019

Talking with your providers about your healthcare needs and coverage

Lorraine York Edberg

How can I communicate effectively with my providers?

Be prepared

Arrive at your doctor’s office prepared with any relevant insurance cards, a copy of your health history, and a list of questions you want to ask your doctor. Bring a pen and paper to take notes, and consider bringing another person, like a caregiver, to your appointment if you think they can help.

Share information

Tell your doctor about any current symptoms or concerns, or if you are having trouble with activities of daily living, like bathing or dressing. Tell them also about other providers you have seen and any treatments they recommended.

Ask questions

If you do not understand something your doctor says, ask them to explain it.

Get it in writing

Ask your doctor to write down what you should do between now and your next visit, including instructions for how to take medications, specialists you should see, and/or lifestyle modifications.

Follow up

If you experience any problems after your appointment, call your doctor’s office to schedule a follow-up. Ask your provider’s office if they use email or an online portal to communicate with patients.

What if my provider doesn’t think a service will be covered?

If you have Original Medicare

When going to an appointment with your medical provider, there are steps you can take before, during, and after the appointment to make the most of your visit.If you have Original Medicare and your provider believes, based on Medicare’s coverage rules, that Medicare will not pay for an item or service, they may ask you to sign an Advance Beneficiary Notice (ABN) before you receive that service.

The ABN allows you to decide whether to get the care in question and to accept financial responsibility for the service if Medicare denies payment. The notice must explain why the provider believes Medicare will deny payment. Providers are not required to give you an ABN for services or items that are never covered by Medicare, such as hearing aids.

Note that your providers are not permitted to give you an ABN all the time or to have a blanket ABN policy.

If you have a Medicare Advantage plan

If you have a Medicare Advantage plan, you or your provider should contact your plan to request a formal determination about whether an item or service will be covered.

If the plan denies coverage before you receive the service, you should get a Notice of Denial of Medical Coverage within 14 days of requesting the determination (or within 72 hours if you request an expedited appeal and your plan approves your request).

Follow the instructions on this notice to appeal your plan’s determination. Ask your doctor to submit evidence to the plan that you meet the coverage criteria for the item or service and that it is medically necessary. If you need assistance filing an appeal, contact your State Health Insurance Assistance Program (SHIP) for information and counseling about the appeals process. See the last page for contact information.

Does Medicare cover second and third opinions?

A second opinion is when you ask a doctor other than your regular doctor for their view on symptoms, an injury, or an illness you are experiencing in order to better help you make an informed decision about treatment options.

Original Medicare covers second opinions if a doctor recommends that you have a surgery or major diagnostic or therapeutic procedure. Medicare does not cover second opinions for excluded services, like cosmetic surgery.

Medicare will also cover a third opinion if the first and second opinions are different from one another. The second and third opinions will be covered even if Medicare will not ultimately cover your procedure (unless it is an excluded service). If the first and second opinions were the same but you want a third opinion, you may be able to see a third doctor for a confirmatory consultation.

Medicare may cover a confirmatory consultation if your doctor submits the claim correctly and the service is reasonable and medically necessary.

If you are in a Medicare Advantage plan, your plan may have different cost and coverage rules for second and third opinions. Contact your plan for more information about costs and restrictions.

The SHINE Program, Serving the Health Insurance Needs of Everyone… with Medicare, provides free, confidential, and unbiased health insurance counseling for Medicare beneficiaries. To reach a trained and certified counselor in your area, contact the regional office at 1-800-498-4232 or 413-773-5555 or contact your local council on aging.