Where to find your Medicare benefits information

Your Medicare benefits are recorded in a government database, and you can look them up yourself without calling anyone. The fastest way is to log into Medicare.gov using your Medicare number and a password you create. Once you are logged in, you can see your coverage details, what you have paid so far this year, and which doctors and hospitals are in your plan's network.

If you do not have internet access or prefer to speak with someone, you can call 1-800-MEDICARE (1-800-633-4227). The line is open 24 hours a day, seven days a week. Have your Medicare card handy when you call. A representative can tell you what your plan covers, what your out-of-pocket costs are, and whether a specific doctor or treatment is included.

Your Medicare plan also sends you a document called the Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC) once a year. This booklet lists what is covered, what is not, and what you pay for each service. If you have lost yours, you can request a new copy from your plan by phone or through their website.

Key Takeaways

  • Log into Medicare.gov with your Medicare number to see your coverage, costs paid so far, and in-network providers.
  • Call 1-800-MEDICARE to speak with a representative who can answer questions about what your plan covers and what you owe.
  • Your plan sends you an Evidence of Coverage booklet each year that lists covered services, exclusions, and your cost-sharing amounts.
  • Before you have a procedure or fill a prescription, ask your doctor or pharmacist to check your coverage so you know what you will pay.
  • If your coverage changed or you think there is an error, contact your plan directly — they can correct records faster than Medicare.

What information you can find online

When you log into your Medicare account at Medicare.gov, you can see several things at once. Under "My Health Care Team," you can view which doctors, specialists, and hospitals are in your plan's network. Under "My Claims and Statements," you can see what services you have used, what Medicare or your plan paid, and what you paid out of pocket. This is useful if you want to track your deductible or see how close you are to your out-of-pocket maximum.

You can also search for specific drugs on Medicare.gov to see if they are covered under your plan and what you will pay. Type the drug name into the prescription drug search tool, enter your plan name, and the site will show you the cost tier, whether you need prior approval from your plan, and which pharmacies have it in stock. This matters because the same drug can cost different amounts depending on which pharmacy you use.

If you are thinking about switching plans during the open enrollment period, Medicare.gov lets you compare plans side by side. You can see the premiums, deductibles, and out-of-pocket limits for each option in your area, which helps you understand what your costs would be under a different plan.

Understanding your cost-sharing amounts

Medicare breaks your costs into several categories: premiums (what you pay monthly), deductibles (what you pay before coverage starts), copayments (a fixed amount per visit), and coinsurance (a percentage of the cost). Your plan documents will list each one. For example, you might pay a $15 copay for a doctor visit, but 20 percent coinsurance for an X-ray after you meet your deductible.

Your out-of-pocket maximum is the most you will pay in a calendar year for covered services. Once you reach it, your plan pays 100 percent of covered costs for the rest of that year. This number varies by plan and changes each year. Knowing your out-of-pocket maximum helps you budget for the year and understand when your costs will stop.

Some services have different cost-sharing rules. For instance, preventive care like annual wellness visits and cancer screenings are usually covered with no cost to you. But if your doctor finds something during a preventive visit and does additional testing, that testing might have a copay or coinsurance. Ask your doctor ahead of time if a visit is preventive or diagnostic so you know what to expect.

How to check coverage before you have a procedure

Before you schedule a procedure, test, or surgery, ask your doctor's office to check your coverage with your plan. Give them your Medicare number and plan name. They can submit what is called a prior authorization request to find out whether your plan will cover the procedure and what you will owe. This step takes a few days but prevents surprises on your bill later.

If your doctor says the procedure is not covered or your plan requires you to try a different treatment first, you have the right to ask why. Your plan must give you a reason in writing. If you disagree, you can file an appeal — your plan's Evidence of Coverage explains how. Many people win appeals by showing their doctor recommended the procedure as medically necessary.

For prescription drugs, ask your pharmacist to check your coverage before you fill the prescription. If your plan does not cover the drug or requires prior approval, your pharmacist can tell you right away. Your doctor may be able to prescribe a different drug that your plan does cover, or submit a request to your plan asking them to cover the one your doctor chose.

What to do if you find an error

If you see a charge on your statement that you do not recognize, or if your plan says a service is not covered when you think it should be, contact your plan first. Call the customer service number on the back of your Medicare card. Have your claim number or the date of service ready. Your plan can often correct errors or explain why a charge was made.

If your plan does not fix the error, you can file a complaint with Medicare itself. Go to Medicare.gov and look for "Submit a Complaint" under the Help section. You can also call 1-800-MEDICARE and ask to file a complaint. Medicare will investigate and contact your plan on your behalf.

Keep copies of all your medical bills, explanation of benefits statements, and any letters from your plan. If there is a dispute about what you owe, these documents prove what happened and when. Many billing errors are caught and corrected within 30 days if you report them quickly.

When to contact your plan directly

Your Medicare plan — whether it is Original Medicare, a Medicare Advantage plan, or a Medigap policy — has its own customer service line. Call the number on the back of your card if you have questions specific to your plan, such as whether a particular doctor is in network, what your copay is for a specific service, or whether you need prior approval for a procedure. Plan representatives can answer these questions faster than Medicare can because they have your plan's details in front of them.

Contact your plan if you move to a new address, change your phone number, or update your emergency contact information. Your plan uses this information to send you important notices and bills. If your address is wrong, you might miss notices about coverage changes or appeals important date.

If you are unhappy with your plan or think a different plan would be better for you, your plan's customer service team can also explain your options for switching. You can change plans during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event like moving or losing other coverage.

Frequently Asked Questions

How do I create a Medicare.gov account if I have never logged in before?

Go to Medicare.gov and click "Sign In" in the top right corner. Choose "Create an Account" and enter your email address. You will need your Medicare number (on your card), Social Security number, and date of birth. Medicare will send you a confirmation email. Click the link in that email to finish setting up your account.

What if I do not have my Medicare number handy?

Your Medicare number is on your Medicare card, but if you cannot find it, call 1-800-MEDICARE and have your Social Security number and date of birth ready. The representative can look up your number and help you with your question. You can also create a Medicare.gov account using your Social Security number instead of your Medicare number.

Can I see what my doctor is charging Medicare for my visit?

Yes. Your Explanation of Benefits statement shows what your doctor billed, what Medicare or your plan paid, and what you owe. You can view these statements online through Medicare.gov or ask your plan to mail them to you. If the amount seems wrong, contact your doctor's billing office to ask why they charged that amount.

What does it mean if my plan says a service requires prior authorization?

Prior authorization means your plan wants to review the service before you have it to make sure it is medically necessary and covered under your plan. Your doctor's office usually handles this by submitting paperwork to your plan. It typically takes three to five business days. Your plan will tell your doctor whether they approve it, deny it, or need more information.

How often does my coverage information change?

Your coverage can change on January 1 each year if you stay in the same plan, because deductibles, copays, and out-of-pocket limits reset. If you switch plans, your new coverage starts on the first day of the month after your plan change is processed. Your plan will send you a new Evidence of Coverage document before any changes take effect.