Medicare Toolkit: Enrollment, Coverage Decisions, Appeals, and Cost Assistance

Tool 1—Employer coverage verification request

To: [Benefits Administrator], [Employer] From: [Name], [Employee ID] Re: Confirmation of group health plan coverage for Medicare purposes

I am approaching Medicare eligibility and need written confirmation of the following, which determines whether I may delay Part B enrollment without a lifetime penalty:

1. Whether the group health plan coverage in which I am enrolled is based on current employment status (mine or my spouse's).
2. The number of employees employed by the company—specifically, whether the company employs 20 or more employees.
3. The start date of my coverage and, if applicable, the anticipated end date.
4. Whether the plan's prescription drug coverage is creditable for Medicare Part D purposes.

I also request that the benefits office complete the Social Security request for employment information form when I retire, and I attach a blank copy now so it may be prepared in advance.

Thank you.

Why it matters. The 20-employee threshold decides primacy. Below it, Medicare pays first and delaying Part B can leave a person functionally uninsured. Get this in writing while you are still an employee.

Tool 2—Enrollment decision worksheet

Tool 3—Medigap comparison worksheet

Benefits within a plan letter are standardized by law. Compare only these:

Note. Attained-age policies start cheapest and rise fastest. Community-rated policies start higher and rise slower. Over twenty years the ordering usually reverses.

Tool 4—Advantage vs. original Medicare worksheet

Tool 5—Observation status inquiry (say this out loud, day one)

"I want to know my status. Am I admitted as an inpatient, or am I under observation? Please put the answer in my chart and give it to me in writing.

If I am under observation, I am asking the attending physician to reconsider the status based on my clinical presentation, because observation days do not count toward the three-day inpatient stay that Medicare requires for skilled nursing coverage.

Before any discharge to a skilled nursing facility, I want written confirmation from the case manager that a qualifying three-day inpatient stay exists."

Repeat daily. Status can change and nobody will tell you.

Tool 6—Expedited appeal script (services ending)

"I received a Notice of Medicare Non-Coverage dated [date] stating that my [hospital / skilled nursing / home health / hospice] services end on [date].

I am requesting an immediate expedited review by the Quality Improvement Organization. I understand services continue during the review and that there is no cost to me.

My name is [ ], my Medicare number is [ ], the provider is [ ], and the notice date is [ ].

I am also requesting the detailed notice explaining the specific reason for the termination, and I have asked my treating physician for a statement supporting continued need."

Deadline: by noon the day before the stated end date. The number is on the notice.

Tool 7—Demand bill request

To: [Provider billing office] Re: Request to submit claim to Medicare—[patient], [Medicare number], dates of service [ ]

You have advised that Medicare will not cover the services described above. I do not agree, and I am formally requesting that you submit the claim to Medicare so that Medicare—not the provider—makes the coverage determination.

I understand I may be responsible if Medicare denies the claim, and I accept that risk in order to obtain an appealable determination. Please provide me with a copy of the claim as submitted and notify me of the Medicare Summary Notice date.

Why. Without a submitted claim there is no determination and therefore nothing to appeal. This converts a provider's judgment into Medicare's.

Tool 8—Redetermination request (Level 1)

To: [Medicare Administrative Contractor], [address] Re: Request for Redetermination—Beneficiary [name], Medicare number [ ], Claim [ ], Date of service [ ], Provider [ ]

I request redetermination of the denial reflected on the Medicare Summary Notice dated [ ]. The denial code stated is [ ], described as [ ].

The coverage rule. [Quote the statute, regulation, national coverage determination, or the local coverage determination applicable in this contractor's jurisdiction. Attach it.]

Application.

1. [Element one]—satisfied because [facts, record citation].
2. [Element two]—satisfied because [facts, record citation].
3. [Element three]—satisfied because [facts, record citation].

Enclosures. (1) Treating physician's letter of medical necessity; (2) [records]; (3) [orders]; (4) [the applicable coverage determination]; (5) Medicare Summary Notice.

Please direct correspondence to [address / phone]. If additional information would assist, contact me before issuing a decision.

Deadline: 120 days from the Medicare Summary Notice.

Tool 9—Physician letter of medical necessity (template to draft for signature)

Re: [Patient], DOB [ ], Medicare number [ ]

I am the treating [specialty] for the above patient and have cared for [him/her/them] since [date].

Diagnosis and severity. [Diagnosis, staging, functional limitations, objective findings.]

Treatment history. [What has been tried, for how long, with what result; why alternatives are inadequate, contraindicated, or previously failed.]

Why this service is medically necessary for this patient. [Specific clinical reasoning—not generic.]

Consequence of denial. Without [service], I expect [specific deterioration, hospitalization, loss of function], based on [clinical basis].

Coverage criterion. [Service] is reasonable and necessary for the diagnosis and treatment of this patient's [condition] and satisfies [the cited criterion] because [tie the clinical facts to the criterion's words].

[Signature, credentials, NPI, date]

The last paragraph is the one that decides cases. Do not omit it.

Tool 10—Advantage plan appeal argument block

The plan's denial applies internal criteria that are more restrictive than original Medicare's coverage rules. A Medicare Advantage organization may not deny a service that would be covered under original Medicare, and its clinical criteria may not narrow the statutory benefit.

Under original Medicare, [service] is covered when [criterion], as set out in [national or local coverage determination / manual provision], attached. The record establishes each element, as detailed above. The plan's requirement of [the extra criterion the plan applied] appears nowhere in the Medicare rule and cannot be the basis for denial.

Tool 11—Drug exception requests

Formulary exception

I request a formulary exception for [drug, strength, quantity]. The prescriber's supporting statement is attached and states that all formulary alternatives—specifically [list]—would not be as effective and/or would cause adverse effects. I request expedited review because delay could seriously jeopardize the patient's health.

Tiering exception

I request a tiering exception placing [drug] at the [tier] cost-sharing level. The prescriber's statement, attached, establishes that the preferred alternatives on that tier—[list]—would not be as effective or would cause adverse effects.

Step therapy exception

I request an exception to the step therapy requirement for [drug]. The patient has [already tried and failed / is medically contraindicated for / is expected not to respond to] [required first-line drug], as documented at [record citation].

Transition fill

The patient is [a new enrollee / affected by a mid-year formulary change]. I request the transition supply required for this circumstance while the exception request is pending.

Timeframes: 72 hours standard, 24 hours expedited.

Tool 12—IRMAA life-changing event request

To: Social Security Administration Re: Request for reduction of income-related monthly adjustment amount—[name], [SSN last four]

I request that my Part B and Part D income-related adjustment be recalculated using my current income rather than the tax return from [year].

Life-changing event: [work stoppage / work reduction / marriage / divorce or annulment / death of spouse / loss of income-producing property / loss or reduction of pension income / employer settlement payment], which occurred on [date].

Evidence attached: [retirement letter, death certificate, decree, pension notice, or other proof], plus [current-year tax return or estimate with supporting documentation].

My modified adjusted gross income for [year] is expected to be $[ ], which corresponds to [no adjustment / a lower bracket].

Routinely granted, rarely requested. File it the year you retire.

Tool 13—QMB balance-billing letter

To: [Provider] Re: Improper billing—[patient], Medicare number [ ], account [ ]

The patient is enrolled in the Qualified Medicare Beneficiary program. Federal law prohibits billing a QMB-enrolled beneficiary for Medicare deductibles, coinsurance, or copayments. Providers must accept Medicare and any Medicaid payment as payment in full.

I request that the balance of $[ ] be removed, that any collection activity cease, and that any adverse credit reporting be withdrawn. Proof of QMB enrollment is attached.

A copy of this letter is being sent to [state Medicaid agency] and to 1-800-MEDICARE.

Tool 14—Appeal deadline calendar

Tool 15—Contact and call log

Ask for the reference number every time. Ask the representative to identify the rule they are applying. Convert every verbal denial into a written one—a verbal denial cannot be appealed.

Tool 16—Cost assistance screening

Have a SHIP counselor screen for all of these in one appointment. They are free and they are not paid by insurers.

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Related documents

• Medicare: Enrollment, Coverage, Appeals, and What It Does Not Pay For
• Enrolling in and Appealing Medicare
• Medicare Enrollment and Appeal Checklist
• Health Insurance Appeal Toolkit
• Elder Law Toolkit
• Personal Injury Claim Toolkit

Templates are starting points, not filings. Amounts, thresholds, and plan rules change annually; Medigap rights vary by state. Verify before sending.