Turning 65 brings a lot of changes. You become eligible for Medicare and have to make important choices about your health coverage. Many seniors opt for Medicare Advantage Plans instead of Original Medicare. But these plans aren’t always straightforward when it comes to coverage and appeals.
As a Medicare beneficiary, you have rights. Medicare Advantage Plans must cover all the services Original Medicare does, with limited exceptions. But coverage limits and denials happen. Knowing the rules can help you access the care you need.
This blog post will cover:
- Medicare Advantage Plan basics
- Required coverage under Medicare Advantage
- Examples of permissible coverage denials
- The appeals process
- Prescription drug coverage issues
- Where to turn for help
Let’s get started untangling Medicare Advantage Plan coverage and appeals.
Medicare Advantage Plan Coverage 101
First, a quick Medicare Advantage refresher. Medicare Advantage Plans are offered by private insurers approved by Medicare. They bundle Part A, Part B, and usually Part D prescription drug coverage into a single plan. Some benefits may be expanded beyond Original Medicare, like dental or vision coverage.
Plans come in a few main types:
- HMOs with restricted provider networks
- PPOs that offer both in and out-of-network coverage
- Private fee-for-service plans with more provider flexibility
Nearly half of Medicare enrollees choose Medicare Advantage Plans over Original Medicare. But these plans have different rules and restrictions that impact coverage.
Medicare Advantage Plans Must Cover Medically Necessary Services
Medicare created standards around Advantage Plan coverage. Plans must cover all services Original Medicare does, except for hospice care. They can’t deny you access to “medically necessary” care. This includes care that:
- Prevents disease
- Helps you regain health after illness, injury, or surgery
- Treats existing health conditions
- Helps maintain current health status
Medicare Advantage Plans must cover treatment your doctor says is necessary. Coverage can only be denied if it doesn’t meet Medicare’s definition of “medical necessity.”
Examples of Potential Coverage Denials
Certain coverage limitations are allowed under Medicare Advantage. For example:
Prior authorization – Some plans require approval before getting non-emergency services. You may need to provide medical records and documentation that shows the care is medically necessary.
Step therapy – You may need to try less expensive medication options before the plan covers more expensive drugs.
Excluded providers – HMOs have network restrictions and may not cover out-of-network providers. PPOs offer flexibility but may charge higher costs for out-of-network care.
Benefit limits – Plans can limit quantities of some services, like physical therapy visits or hearing exams. Make sure you understand any coverage limits.
Extra benefits – Medicare Advantage Plans may offer dental, vision, gynecology or hearing benefits. But these are considered “extra” benefits that plans can restrict.
Prescription drugs – Formularies may exclude certain brand name or expensive drugs. We’ll cover appeals for prescription medications later.
How to Appeal a Medicare Advantage Coverage Denial
If your plan denies coverage you think should be covered, you can file an appeal. This involves a formal review of the decision. Appealing gives the plan another chance to approve coverage.
Here are key steps in the Medicare Advantage appeals process:
File quickly – You have 60 days from the denial notice date to start your appeal. Meet this deadline to keep your options open.
Request a review – Ask your plan for a copy of your denial notice. It should explain why coverage was denied. File a written appeal request according to the directions.
Provide evidence – Include documents that support your case, like letters from your doctor or medical records. Explain why the denied care is medically necessary for your situation.
Consider hiring help – A lawyer or advocate familiar with Medicare appeals may be able to help navigate the process.
Expect multiple levels of review – First your plan reconsiders the decision. If they uphold the denial, you can request review by an independent mediator. Finally, if needed, a judge may review your appeal.
Persistence and patience pays off. About half of plans overturn denials during the appeals process, according to Kaiser Family Foundation (KFF). Stick with it to get the coverage you deserve.
Appealing Prescription Drug Coverage Denials
What if your Medicare Advantage Plan won’t cover a prescription drug your doctor says you need? This is common for expensive brand name drugs or medications not on your plan’s formulary.
First, ask your doctor about alternatives on your plan’s approved drug list. However, you have the right to appeal if only the excluded medication treats your condition.
To appeal, provide a statement explaining why other drugs don’t work as well for you. Your doctor can submit a “Letter of Medical Necessity” to back up your appeal.
During the appeals process, ask your doctor for samples or coupons to temporarily lower your medication cost. Alternatively, you can pay out-of-pocket for the drug while awaiting the decision. Make sure to save receipts so you can request reimbursement if you win the appeal.
Where to Get Help with Medicare Advantage Appeals
Navigating coverage denials and appeals can be frustrating. These government resources offer help:
- 800-MEDICARE – Medicare agents can check claim status, start appeals, and more.
- State Health Insurance Assistance Program (SHIP) – Local counselors provide free Medicare help.
- Medicare Rights Center – Experts assist with appeals at no cost.
- Medicare Ombudsman – The ombudsman investigates complaints about Medicare.
Arming yourself with information is the best defense against improper coverage denials. Use this guide to understand required Medicare Advantage Plan coverage and how to appeal. Reach out for help when you need it. With persistence, you can get access to the health services Original Medicare promises.
We’re Here to Help
You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give Scott Sims at Sims Insurance Medicare Plans a Call at (541) 915-0939. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.
Can you be turned down by Original Medicare Plan and Medicare Advantage Plan?
Yes, Medicare Advantage Plans can deny coverage for certain individuals. They have the right to deny coverage based on specific circumstances and criteria.
What are some reasons why a Medicare Advantage Plan may deny coverage?
Medicare Advantage Plans can deny coverage for various reasons, such as pre-existing conditions, not meeting enrollment criteria, or if the plan does not operate in your area.
What are pre-existing conditions?
Pre-existing conditions refer to any health condition that you had prior to enrolling in a Medicare Advantage Plan. Some plans may deny coverage or impose restrictions based on pre-existing conditions.
Can Medicare Advantage Plans deny coverage for pre-existing conditions?
Yes, some Medicare Advantage Plans can deny coverage or impose restrictions for individuals with pre-existing conditions. However, there are other options like Medicare Supplement Plans that may provide coverage even with pre-existing conditions.
What is the difference between a Medicare Advantage Plan and a Medicare Supplement Plan?
A Medicare Advantage Plan is an alternative way to receive your Medicare benefits, usually through a private insurance company. A Medicare Supplement Plan, also known as Medigap, helps fill the gaps in coverage that Original Medicare does not cover.
When can I enroll in a Medicare Advantage Plan?
You can enroll in a Medicare Advantage Plan during the initial enrollment period or during the annual open enrollment period. The initial enrollment period is when you first become eligible for Medicare, and the annual open enrollment period is from October 15th to December 7th each year.
Can a Medicare Advantage Plan deny coverage for prior authorization?
Yes, some Medicare Advantage insurance plans may require prior authorization for certain services or medications, and they have the right to deny coverage if the prior authorization is not obtained.
Can a Medicare Advantage Plan deny coverage for pre-existing conditions?
Yes, some Medicare Advantage Plans can deny coverage or impose restrictions based on pre-existing conditions. However, they are required to cover all services and treatments that Medicare Part A and Part B cover.
Can a licensed insurance agent help me with enrolling in a Medicare Advantage Plan?
Yes, a licensed insurance agent can help you understand your options and guide you through the process of enrolling in a Medicare Advantage Plan. They can provide unbiased advice and help you compare different plans.
Are all Medicare Advantage Plans allowed to deny coverage?
Yes, every Medicare Advantage Plan has the ability to deny coverage, but they must follow the coverage rules set by the federal Medicare program.