Using Medicare day-to-day — the practical workflows.

Call the office before your first visit. Ask: 'Do you accept Medicare assignment?' If yes, they'll bill Medicare directly and accept the Medicare-approved amount. If no, they may charge up to 15% above Medicare-approved (excess charges) — and Plan F or G covers excess charges, others don't. Most providers accept assignment.

Original Medicare: bring your federal Medicare card (red/white/blue). If you have a Medigap plan, also bring that card. Medicare Advantage: bring ONLY your MA plan card — your federal Medicare card isn't used at the visit.

The provider's billing staff scans/copies your card(s). Provide your insurance information when registering. Most offices verify benefits before the visit.

Original Medicare: typically nothing for preventive services, or your $257 Part B deductible (annual) if not yet met, then 20% coinsurance. Medigap (Plan G or F) covers the 20%. MA plan: copay per visit (usually $0-$30 for primary care, $30-$70 for specialist).

The provider bills Medicare or your MA plan. You receive a Medicare Summary Notice (Original) or Explanation of Benefits (MA/Medigap) within 30-90 days showing what was billed, what was paid, and what you owe.

Each Part D plan (or MA-PD plan) has a pharmacy network. Some pharmacies are 'preferred' (lower copays), others are 'standard' (higher copays). Call your plan or check their pharmacy locator before filling at a new pharmacy.

Show your Part D plan card (or MA-PD card if drugs are bundled). Original Medicare card alone does NOT cover most prescriptions.

Part D plans use a tier system: Tier 1 (preferred generic, often $0-$5), Tier 2 (generic, $10-$20), Tier 3 (preferred brand, $35-$50), Tier 4 (non-preferred, $50-$100), Tier 5 (specialty, often coinsurance like 25-33%). Same drug can be different tiers on different plans — that's why our $49 comparison ranks by YOUR exact medications.

If your drug requires prior authorization, the pharmacist will tell you the claim was rejected pending PA. Your doctor's office files the PA paperwork with your plan; approval typically takes 24-72 hours. Plan ahead — don't run out of medication.

Once your annual Part D out-of-pocket reaches $2,100, you pay nothing for the rest of the year. Track your progress on your plan's app or member portal — for high-cost medications this matters a lot.

Most plans offer mail-order pricing that's significantly cheaper than monthly retail. Common for maintenance medications. 90-day fills at preferred retail pharmacies are sometimes also discounted. Ask your plan.

ASK EXPLICITLY: 'Am I admitted as inpatient or kept under observation?' This determines whether Part A (inpatient) or Part B (observation) applies — and it affects whether your stay counts toward the 3-day requirement for Skilled Nursing Facility coverage afterward. Observation can mean SNF coverage doesn't kick in even if you spent 4 nights in the hospital.

If your physician expected you'd stay 2+ midnights, you should be inpatient (Part A). If under 2 midnights expected, you're observation (Part B). Mistakes happen — ask about this and request a status change if appropriate.

$1,676 Part A deductible per benefit period. Days 1-60: $0 coinsurance after deductible. Days 61-90: $419/day. Days 91+ (lifetime reserve): $838/day, max 60 lifetime reserve days. Plan G/F covers all of this.

MA plans typically require prior authorization for inpatient admissions (except true emergencies). The hospital usually handles this, but for non-emergency procedures, get pre-authorization in writing before scheduling.

Within 2 days of admission, you receive an Important Message from Medicare. It explains your right to appeal if you disagree with discharge. If you think you're being discharged too early, request a Quality Improvement Organization (QIO) review BEFORE you leave.

Medicare covers DME only with a prescription stating it's medically necessary. The prescription must be from a Medicare-enrolled provider. Walker, oxygen, CPAP, hospital bed, manual or power wheelchair, blood glucose monitor, etc.

The supplier must be enrolled in Medicare. Use the supplier directory at medicare.gov to find approved options. Buying from a non-approved supplier means Medicare pays nothing.

Some DME (walker, manual wheelchair) is purchased. Some (oxygen equipment, CPAP, hospital bed) is rented for 13 months and then transferred to you. The supplier handles the billing logistics.

Original Medicare: 20% of the Medicare-approved amount after the Part B deductible. Plan G/F covers the 20%. MA plan: typically a copay per item or coinsurance.

DME denials are common. Common reasons: prescription not specific enough, supplier not in network, item not Medicare-covered. Work with your doctor's office to provide additional documentation, then appeal. Almost half of DME appeals are reversed in the beneficiary's favor.

First, check your MSN/EOB. Did Medicare/your plan actually pay the claim? If yes and the provider is still billing, call the provider's billing office with your MSN/EOB in hand. Most billing errors are resolved with one call.

Original Medicare: 5 levels of appeal. Level 1 (Redetermination): file within 120 days, decision in 60 days. Levels escalate to Reconsideration, ALJ hearing, Appeals Council, and federal court. Half of appealed denials are overturned. MA plan: appeal directly to the plan; CMS has fast-track timelines for urgent cases.

They may have opted out (which is allowed but rare for established practices). Verify by calling Medicare. Find a new provider who does accept Medicare via the medicare.gov 'Find a doctor' tool.

The No Surprises Act (2022) applies to most surprise out-of-network billing for emergency services and certain non-emergency situations. If you receive a surprise bill, dispute it via the No Surprises Act portal at cms.gov/nosurprises.

State Health Insurance Assistance Programs (SHIP) provide free Medicare counseling. Senior Medicare Patrol (SMP) helps with fraud and billing problems. Both are funded by federal grants and provide unbiased help — no commissions, no agents calling you.