РусскийAs licensed Medicare brokers with years of experience, we’ve seen that most Medicare issues don’t happen during enrollment—they arise mid-year, when you’re actually using your coverage. From billing surprises to provider changes, this article outlines 5 common mid-year Medicare problems and how to handle them.
We’ve included real-life case examples, actionable tips, and linked to official sources like Medicare.gov and CMS.gov to help you navigate these challenges confidently.
1. Unexpected Medical Bill – A Service Wasn’t Covered
What Happens:
You go in for a routine service. A few weeks later—bam! A bill arrives for hundreds or even thousands of dollars.
Common Reasons:
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The service is not covered by Medicare (e.g., acupuncture, cosmetic procedures, alternative therapies);
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No prior authorization was submitted (a common issue with Medicare Advantage plans); https://medicareadvocacy.org/prior-authorization/
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Your provider is out of network;
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A billing or coding error caused the claim to be denied.
What to Do:
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Check your plan’s provider network if you’re on a Medicare Advantage (Part C) plan;
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Ask if the service needs prior authorization before it’s performed;
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Review your Explanation of Benefits (EOB) for details;
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Contact your licensed Medicare broker to help file an appeal.
Real Example:
A patient’s surgery was denied. We discovered the provider didn’t include enough clinical info in the prior authorization request. After resubmission, the surgery was approved.
2. Prescription Drug Prices Increased
Why It Happens:
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Your medication was removed from the formulary or moved to a higher tier;
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Your plan changed pricing from copay to coinsurance;
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You’re using a non-preferred pharmacy;
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You lost Extra Help, which previously lowered your copays;
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Your drug now requires prior authorization or step therapy. https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-prior-authorization-and-step-therapy-part-b-drugs
How to Fix It:
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Ask your doctor to submit a formulary exception request;
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Confirm if the medication requires step therapy or authorization;
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Switch to a preferred network pharmacy;
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Reapply for Extra Help through SSA.gov.
Real Example:
A client used to pay $9 for an inhaler. After losing Extra Help, it jumped to $137. We helped her requalify, and her original cost was restored.
3. You Moved and Your Plan No Longer Works
Important Notes:
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Medicare Advantage and Part D plans are based on your ZIP code;
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If you move out of your service area, your plan may become invalid;
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Moving triggers a Special Enrollment Period (SEP), which gives you 2 months to choose a new plan.
What to Do:
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Inform Social Security and your insurance company of your new address;
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Contact your broker or us to enroll in a new Medicare Advantage or Part D plan for your new location;
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If you have a Medicare Supplement plan, review if it’s still cost-effective in your new state.
Real Example:
A couple moved from Illinois to Texas but kept using their old plan. A month later, their claims were denied. We helped them enroll in a new local plan immediately.
4. You Lost Medicaid, Extra Help, or Medicare Savings Program
Why It Happens:
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You missed your annual recertification;
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Your income or asset levels changed;
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You moved to a new state, where eligibility rules differ;
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Your immigration or household status changed.
How to Fix It:
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Review eligibility;
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Reapply for benefits via SSA or your state Medicaid office;
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Use your Special Enrollment Period to change your Medicare Advantage or Part D plan.
Real Example:
A client lost Extra Help because of a reporting error on income. We corrected the mistake and reinstated his benefits.
5. You Need to Change Your Primary Care Physician (PCP)
If You Have Medicare Advantage:
You’re required to choose a PCP within your plan’s network. The good news: you can change your PCP at any time—no need to wait for the Annual Enrollment Period (AEP).
Steps to Switch:
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Go to your insurance company’s website;
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Find in-network providers accepting new patients;
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Call your insurance company to update your PCP;
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Confirm the change via online portal or mail.
If You Have Original Medicare:
You can see any doctor who accepts Medicare—no PCP designation required.
Real Example:
A woman in New Jersey was frustrated with long wait times at her PCP. We helped her find a new, in-network doctor who had immediate availability.
Need Help with Medicare?
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Call: 616-600-8444
Chief Insurance Services – Licensed in all 50 states
Service available in English, Russian, and Ukrainian
Free help with:
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Choosing a plan
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Pre Qualifying for Medicaid, Extra Help, or MSP
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Filing appeals or changing doctors
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Understanding your rights