“They told his wife he had to leave”
He was already my client. Then his wife called me — he was in a skilled nursing facility, and they'd told her that after day 20 his insurance wouldn't cover him.
That's not what was happening. Medicare covers a skilled nursing stay up to 100 days. Many Advantage plans mirror that: nothing for the first 20 days, then a daily copay after. Coverage doesn't stop on day 21 — the patient just starts paying. What the facility was really doing was managing its own risk of not getting paid.
The part that worries me most is what facilities often suggest next: drop your Advantage plan and go back to Original Medicare. That's good for the facility. For the patient it can mean $217 a day with nothing to cover it, no drug coverage, and no easy way back.
I found him coverage that paid the whole stay with no daily copay, then drove to the facility and showed them in person exactly what he was entitled to.
He stayed 45 days — twenty-five past the day they said he had to be out. He still thanks me for it.
You can push back without an agent, too. The facility must give you written notice at least two days before Medicare coverage ends, and you have the right to a fast independent review before any discharge. Most families are never told that.
If your doctors stop taking your plan…
What the Scripps announcement left out
In 2023, Scripps Clinic and Scripps Coastal announced they would stop accepting Medicare Advantage plans on January 1st. About 32,000 people in San Diego found out their medical group might not be their medical group much longer.
The announcement wasn't the whole picture. They were still taking PPO plans — and a PPO is still a Medicare Advantage plan, it just meant being out of network. That's the difference between changing your plan and changing your doctor, and it wasn't in what people were reading.
So I drove down and asked them in person. The question I wanted answered was the one that actually decides it for a patient: would they have to pay the bill themselves and claim it back afterward? I was told no — they would bill the PPO carrier directly. That was the detail that made the option workable, and there was nowhere to go and read it.
It wasn't the right answer for everyone. But for most of the people I sat down with it was the only one that worked. A lot of them were in their eighties, and a Supplement at that age runs several hundred dollars a month — which put the advice going around, switch to Original Medicare and buy a Supplement, out of reach. More of them ended up on a PPO than on a Supplement.
That's a choice you can only make once somebody has done the legwork. What most people had was a headline.
If you lived outside the U.S. and got a penalty letter…
The penalty that was bigger than her whole check
I met her at a senior center in Menifee. She'd spent most of her adult life outside the country, and when her Medicare card arrived it came with a late-enrollment penalty for every year she hadn't been enrolled — more than her entire monthly Social Security payment. She hadn't applied for Medicare and had no idea how she had it.
Working out where it had come from meant going through her records with her. She qualified on the work history of an ex-husband she hadn't seen in more than a decade — and that told me something more useful. She'd never worked in the U.S. herself, so her own benefit was small enough that she should qualify for Medi-Cal.
So I put the application together and stayed on it until it was approved. About a month. It now covers her Part B premium, her cost-sharing and the penalty, and she keeps her Social Security.
None of that was an enrollment. No plan changed hands — it was records, forms and follow-up for a government program. But it was where her money was, and she had no way of finding it on her own. She's better covered today than if that letter had never arrived.
If you have both Medicare and Medi-Cal…
“We don't take Medi-Cal”
It happens often enough that I now expect it. A client with both Medicare and Medi-Cal gets a bill from a doctor's office. When they question it, they're told the practice doesn't accept Medi-Cal — so the balance is theirs.
That isn't legal. Federal law prohibits any provider who accepts Medicare from billing a Qualified Medicare Beneficiary for Medicare cost-sharing. Whether the practice takes Medi-Cal makes no difference. The penalties reach $20,000 per improperly billed item.
So my clients call me, and I call the billing department. Sometimes staff argue. I tell them, calmly, that I'm not calling to threaten a sanction — I'm calling so they can avoid one.
It gets resolved that day, every time.
