Medicare can be complicated. It’s easy to make mistakes when signing up that could result in lifelong penalties or coverage gaps, and people who lose their jobs after age 65 have an extra layer of complexity. Everyone on Medicare has the opportunity to choose a Medicare Part D or Medicare Advantage plan during open enrollment each year, and the plan you select could make thousands of dollars of difference in your out-of-pocket costs. Low-income people often don’t realize that they’re eligible for extra help to pay Medicare drug costs. And if your care or drug is denied, you can appeal and fight back. You can get help with all of these complicated Medicare issues from your State Health Insurance Assistance Program, or SHIP.
What Is a SHIP?
This federally funded program is managed by the states and provides free counseling to help with Medicare questions and decisions. Every state has a SHIP program (plus the District of Columbia, Puerto Rico and the Virgin Islands). The SHIP is based in the department of aging in about two-thirds of the states, and in the insurance department in the other third, says Rebecca Kinney, director of the Office of Healthcare Information and Counseling for the U.S. Department of Health and Human Services’ Administration for Community Living, which distributes the money to the states. “We want to help people understand Medicare, sort through their options, and get enrolled in the plans that will work best for them,” says Kinney. “The goal is educating and empowering people to get the best out of their Medicare, both through one-on-one counseling and public outreach.”
There are about 16,000 SHIP counselors throughout the country, who have completed a rigorous training program, says Ginny Paulson, director of the SHIP National Technical Assistance Center, which provides SHIPs with information and training resources. About half are volunteers and half are paid staff of a government agency or nonprofit. There are SHIP-trained people in area agencies on aging, senior centers, senior housing complexes, local support organizations and hospitals. For example, Illinois SHIP has about 1,000 counselors in over 300 sites, including about 50 in training at Cook County Hospital, says Sandy Leith, SHIP director for the State of Illinois Department on Aging.
SHIP counselors answer Medicare questions over the phone and also hold seminars and one-on-one sessions to help people with their Medicare decisions – and they’ve been adapting to COVID-19 restrictions this year. They have different names in different states, such as HICAP in California (Health Insurance Counseling and Advocacy Program) and SHINE in Florida (Serving Health Insurance Needs of Elders), and Minnesota uses SHIP money to do Medicare counseling through the Senior LinkAge Line. To find the SHIP program in your area, go to www.shiptacenter.org. You can also get contact information for your local SHIP by calling 800-Medicare.
“The whole premise of the program nationally is to get folks into the communities because they know the nuances of Medicare, and the Medicare Advantage plans and Medigap and different pieces of Medicare are very localized,” says Kinney. “That’s one of the reasons SHIPs are so successful because they’re able to tailor to the needs of their community.”
SHIPs can help with questions about all levels of Medicare. “SHIPs are comprehensive – they help with enrolling in Medicare, knowing the enrollment periods, understanding what’s covered under Medicare, and the different ways you can get Medicare,” says Paulson. They can help with Medicare Advantage, Medigap and Part D questions, too. “They can also help with out-of-pocket costs of Medicare, and they can help with appeals,” she says.
SHIPs help thousands of people every year with their Medicare issues, but many people still don’t know about them. Here are some ways that SHIPs can help with Medicare decisions and questions.
- Open enrollment help.
- Medicare enrollment questions.
- Special help for lower-income people.
- Medicare problems and appeals.
Open Enrollment Help
The busiest time for SHIP counselors is during open enrollment from Oct. 15 to Dec. 7, when people can choose a Part D prescription drug plan or Medicare Advantage plan for the upcoming year. “Pretty much everyone on Medicare can do something during this time,” says Shannon Hohl, the Senior Health Insurance Benefits Advisors program supervisor, which is Idaho’s SHIP program.
SHIPs usually offer open enrollment seminars at several sites throughout their states and also provide one-on-one counseling. In normal times, you’d bring a list of your medications and sit next to the counselor while he or she uses the Medicare Plan Finder to help you pick the best Part D or Medicare Advantage plan for the year.
Because of COVID-19 restrictions, the counselors had to change the way they meet, but they’ve been providing personal counseling through Zoom, GoToMeeting or Webex, where they can share computer screens and walk through the Plan Finder’s results together. They also work with adult children who are helping their parents. Some counselors get permission from Medicare beneficiaries to log into their MyMedicare.gov account and see their last 12 months of drug claims, which can help when comparing the cost of the plans, says Leith.
For people who aren’t comfortable with the technology, the counselors may talk on the phone, get a list of their medications and mail the Plan Finder results showing the premiums and out-of-pocket costs for their medications from the plans in their area.
States have also been coming up with creative solutions to provide one-on-one counseling during the pandemic, says Maggie Flowers, the SHIP/MIPPA program manager for U.S. Department of Health and Human Services’ Administration for Community Living. “In Florida, they’ve been having some drive-through counseling. They prep the beneficiary in advance, and then they come up in the car and have their appropriate gear on and they talk about the plan comparison,” she says.
The Illinois SHIP works with a Chicago organization called the Coalition of Limited English Speaking Elderly to provide counseling and seminars in other languages, such as Chinese.
One-on-one counseling sessions can get booked up, so it’s a good idea to contact your local SHIP early in the open enrollment period to make an appointment. The SHIP programs are also holding virtual open-enrollment seminars and plan to post them on their websites, too.
Medicare Enrollment Questions
SHIPs also provide help with Medicare sign-up issues. Unless you’re already receiving early Social Security benefits at 65, you need to proactively sign up for Medicare. Your sign-up decisions can be complicated if you’re still working past age 65 and have health insurance through your employer, especially if you lose your job and need to make decisions quickly.
You also have several decisions to make about how to fill in the gaps in Medicare – such as with a Medigap and Part D prescription drug plan, or instead of traditional Medicare you can have health care and drug coverage through a private Medicare Advantage plan. The available plans can vary by state and county, and SHIP counselors can help you assess your options in your area.
“We try to reach people at age 64,” says Hohl. “They call us saying they’re planning to retire next year or will be turning 65 and let’s talk about what that means in terms of Medicare and your health insurance.” Her office holds several seminars each year for people who are about to sign up for Medicare (which are now available online) and provides one-on-one counseling, too. They also help people who are under 65 and are eligible for Medicare because of a disability or other medical conditions.
The Medicare sign-up issues became more complicated when Social Security offices were closed because of COVID-19, especially for people enrolling past age 65 who usually couldn’t sign up online (the Social Security Administration recently changed the rules and is permitting post-65 people to sign up online). The SHIP National Technical Assistance Center has a helpful guide for enrolling in Medicare during COVID at https://www.shiptacenter.org/covid-19.
Special Help for Lower-Income People
SHIP counselors can also help people figure out if they’re eligible for extra help with Medicare prescription drug costs or other programs to help with their premiums and expenses. Some organizations do screening for low-income extra help programs automatically as part of other services, but you can also contact the SHIP to find out if you are eligible for any programs. “Anyone who is struggling or concerned about their Medicare costs can contact us,” says Hohl. “Even if they don’t qualify for a program, maybe they could do a plan review and save some money.”
The SHIP counselors can also help with the recertification paperwork for the programs to make sure Medicare beneficiaries continue to receive the extra help. “The SHIPs do a lot of extra work to help you stay enrolled,” says Kinney.
Medicare Problems and Appeals
SHIP counselors can also help with Medicare coverage questions, problems and appeals if your health care or drug wasn’t covered – either by Medicare or from a Medigap, Part D or Medicare Advantage plan.
“If they get a Medicare Summary Notice (which is similar to an explanation of benefits) and it says something isn’t covered and they don’t understand why, they can call Medicare but they can also call us and we can explain what’s going on,” says Hohl. SHIP counselors have special access to the 800-Medicare call center and a unique ID so Medicare knows they’re talking to an experienced person, she says. The SHIP counselors may also contact the Medigap, Part D or Medicare Advantage plans with questions. “We may have the beneficiary on the phone and do a three-way call and help them interpret what’s being said,” she says.
Sometimes they can identify an error before having to do a formal appeal. “It could be a mistake on the provider’s part, the way they coded it,” says Paulson. If they do need to appeal a decision, the SHIP counselors have been trained in Medicare’s specific appeals process.
“HICAPs help Medicare beneficiaries appeal claim denials for any medically necessary services, such as from mammograms, ambulance claims, to surgeries or other treatments, whether they be in original Medicare Part A or B, or Medicare Advantage plans. HICAPs also help with Part D prescription drug coverage denials,” says Tatiana Fassieux, education and training specialist for California Health Advocates, which is a nonprofit organization that supports the state’s SHIP program (HICAPs) with advocacy, client problem resolution and training. “HICAPs help through the first three of five appeal steps and inform clients how to proceed with the next two.”
Bonnie Burns, a training and policy specialist with California Health Advocates, also helps people who contacted the HICAP after trying to sign up for Medigap and were rejected because the insurer didn’t know the California guaranteed issue laws (in most states, Medigap insurers can reject you or charge more based on your health if more than six months have passed since you signed up for Medicare Part B, but California law lets people sign up for certain Medigap plans during the 60-day period starting on their birthday each year, regardless of their health).