In short
- Many people have benefits they never use because nobody walked them through their plan.
- Your Evidence of Coverage lists what your plan covers. Your Annual Notice of Change, due by September 30, lists what changes in January.
- Medicare Advantage plans can offer extra benefits for people with certain chronic conditions, and for 2027 plans must publicly post who qualifies.
- Medicare covers a yearly Wellness visit once every 12 months at no cost to you when your provider accepts assignment.
Most of the stories I can't repeat. This one I'll tell in outline, with the details left out on purpose, because the lesson matters a lot more than the details.
What happened?
I'd been working with this client for a couple of years. During one of our conversations, it came out that something had been bothering her for a long time, well over a year. She figured getting it taken care of would cost money she didn't have, so she just lived with it.
I knew her plan. Because of a medical condition she has, her plan covered care for exactly the problem she'd been living with. She had no idea.
When I told her, she said it was probably too late. I said no, it's not too late. Let's call your doctor right now. So we did. We made the call together and got an appointment on the calendar.
A few months later, I saw her again. The thing she'd put up with for so long was taken care of, and she was back to doing an everyday thing most of us never think twice about.
Here's the part that still gets me. That lady had been on Medicare for probably 10 years, and nobody explained to her, because of this medical condition, you qualify for this.
It's not self-gratification by any means. But that's what it's about.
Why didn't anybody tell her?
Because nobody sat down, went through her benefits with her, and listened long enough to connect the two. I don't think anybody was hiding anything. The information was there. It was just buried.
Your benefits live in your plan's documents, and most people never open them:
- The Evidence of Coverage explains what your plan covers and what you pay. Your plan has to send you a notice or printed copy by October 15.
- The Annual Notice of Change lists what's changing in January. Your plan has to send it by September 30.
They're long, and they read like they were written by a committee, because they probably were. So they go in a drawer.
There's another wrinkle. Medicare Advantage plans can offer additional benefits customized for people with specific conditions and certain chronic illnesses, and you generally find out whether you qualify after you join. Under CMS's rule for 2027, plans have to publicly post the eligibility criteria they use for those benefits. That helps, but only if somebody looks.
And people rarely lead with the real problem. If somebody comes to you with a complaint, that complaint usually isn't the actual problem. It's just what's at the top. You have to keep listening.
What benefits do people already have and not use?
More than you'd think. Some come with Original Medicare, and some depend on your plan.
| Benefit | Who it's for | What to know |
|---|---|---|
| "Welcome to Medicare" preventive visit | Your first 12 months on Part B | You pay nothing if your provider accepts assignment. It's not a physical exam. |
| Yearly "Wellness" visit | Part B for more than 12 months | Covered once every 12 months, and you pay nothing if your provider accepts assignment. It includes a review of your current prescriptions. |
| Chronic care management | Two or more serious chronic conditions expected to last a year or more | Medicare may pay a provider to help manage them. The Part B deductible and coinsurance apply. |
| Medicare Advantage extras | Members of plans that offer them | Dental, vision, hearing or gym benefits may be included, but they're generally limited. Check your plan. |
| Condition-specific plan benefits | Medicare Advantage members with certain chronic conditions | Varies by plan. Ask your plan whether you qualify. |
| Help paying costs | People with limited income and resources | See Medicare Savings Programs and Extra Help. |
Plan availability, premiums, networks and benefits vary by county and change every year. And some things simply aren't covered at all, which is worth knowing too. Here's what Medicare doesn't cover, and how Medicare Advantage extras fit around those gaps.
How do I go through your benefits in a review?
I educate first, then I listen. Most of this job is just listening and making sure people are in the right spot. That spot changes every year, and so does what's in your plan.
Here's what that looks like at my table:
- We start with your medications and doctors, because that's what you use most.
- I ask what's bothering you, including anything you've been putting off because you think it costs too much.
- We look it up in your plan, together, instead of guessing.
- If it's unclear, we call. The plan, the doctor's office, whoever has the answer. Better to spend 10 minutes on hold than another year going without.
That's the heart of my annual enrollment review. It isn't only about whether to switch plans. It's about whether you're using the one you have.
What can you do on your own this week?
You don't need me to start. Here's a short list:
- Find your Evidence of Coverage. It's usually on your plan's website, or call member services using the number on your card.
- Look up your conditions and anything you've been going without. Use the index.
- Ask your plan directly: "Do I qualify for any benefits because of my condition?" Write down who you talked to.
- Book your yearly Wellness visit if it's been more than 12 months.
- Open your Annual Notice of Change when it arrives, so you know what's different for 2027.
If you'd like unbiased help reading your plan, call 1-800-MEDICARE (1-800-633-4227), available 24 hours a day, 7 days a week (TTY 1-877-486-2048), or Nebraska SHIP (formerly SHIIP) at 1-800-234-7119. You can also bring your paperwork to me. My review checklist lists what to bring, and my help costs you nothing. Talk to me, and let's see what you've already got.
Frequently asked questions
The Evidence of Coverage is the document your Medicare Advantage or drug plan sends that explains what the plan covers, how much you pay, and the rules for getting care for the coming year. Plans must send a notice or printed copy by October 15. It's long, but it's the best place to look up a specific service or condition. If you can't find yours, call the member services number on your plan card.
Yes. If you've had Part B for more than 12 months, Medicare covers a yearly Wellness visit once every 12 months, and you pay nothing if your provider accepts assignment. It isn't a physical exam. It's a visit to make or update a prevention plan, and it includes a review of your current prescriptions. Extra tests done during the same visit may cost you coinsurance or a deductible.
Yes. Medicare Advantage plans can offer additional benefits customized for people with specific conditions and certain chronic illnesses. You generally find out whether you qualify after you join the plan. Under CMS's rule for 2027, plans must publicly post the eligibility criteria they use for these benefits. What's offered varies by plan and county and can change every year, so check your plan's current documents.
Start with your plan's Evidence of Coverage and look up your condition and the services you need. Then call member services and ask directly whether you qualify for any benefits because of that condition. You can also ask your doctor's office, a licensed agent, 1-800-MEDICARE or Nebraska SHIP for help reading your plan. Write down who you talked to and what they said.
Chronic care management is a Medicare service for people with two or more serious chronic conditions, like arthritis and diabetes, that are expected to last at least a year. Medicare may pay a health care provider to help manage those conditions, including a care plan, a review of your medicines and help between visits. The Part B deductible and coinsurance apply, so ask your provider what it would cost you.
Sources
- Medicare.gov: Medicare & You 2027 handbook (Evidence of Coverage, Annual Notice of Change, plan extra benefits, chronic care management) (opens in a new tab)
- Medicare.gov: Yearly wellness visits (opens in a new tab)
- Medicare.gov: Welcome to Medicare preventive visit (opens in a new tab)
- CMS: Contract Year 2027 Medicare Advantage and Part D final rule fact sheet (opens in a new tab)
