When Your MA Plan Denies Coverage, What Do You Do?

May 29, 2024

Medicare Part C, more commonly known as Medicare Advantage (MA), has grown in popularity as the health insurance of choice for people aged 65 or older. This really isn’t surprising, as there has been a huge marketing push for the MA plans. In fact, according to the Kaiser Family Foundation (KFF), more than half of Medicare beneficiaries were enrolled in a MA plan. While many beneficiaries like their plan, a denial of coverage for a service or treatment can cause some serious headaches…but it doesn’t have to.

Just the Facts

Many people think that Medicare covers long term care such as nursing home and/or assistance living expenses. However, Medicare doesn’t pay for long term care. It only pays for some rehab, medication, and post-acute services. Learn about your options for paying for long term care.

MA plans are offered by private insurance companies that are approved by Medicare. They are required by law to cover the same hospital, doctor, and outpatient services as traditional Medicare. However, they may have different deductibles and copays. Most MA plan cover prescription medications, but each uses its own formulary, which is a list of drugs they cover and at what dollar amount. Many plans offer some coverage for things traditional Medicare doesn’t pay for such as eye exams and glasses, hearing aids, and dental visits.

You can’t just see any doctor or other practitioner with an MA plan. Instead, most have their own network of practitioners and facilities, and you have to use one of those to get coverage. Most MA plans are either an HMO, in which you generally can choose a primary care doctor who you will need a referral from to see a specialist, or a PPO that has a network of doctors and facilities, but you don’t need a referral for a specialist visit. You may even be able to go outside the network for some care.

It is also important to understand how coverage for different things is decided. In general, most coverage is determined by medical necessity. That is, the treatment, test, procedure, or facility stay is necessary to manage a condition or illness, or maintain or improve your health. The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicare and other healthcare programs in the U.S., has specific coverage determinations and rules based on clinical evidence and best practices.

Why Deny?

Most healthy patients are generally pleased with MA plans. It’s when they are sick and coverage for something is denied that there are problems. However, if your MA plan denies coverage for something, don’t panic. There are steps you can take.

The most common appeal is about length of stay. For example, the MA plan denies a request for an extended stay in a skilled nursing facility for rehab after someone breaks a hip. The covered length of stay is based on what the plan thinks is necessary for the person to get rehab and other services and recover enough to go home or to another setting. However, you might need additional time for various reasons such as the injury isn’t healing as well as expected, progress was complicated by an unexpected illness such as the flu, or there aren’t enough supports (such as family caregivers) to go home safely.

Whatever the denial, you can file an appeal. Every plan has its own appeals process, so the first thing is to find out from your plan what this process is. This information may be in your plan materials, or it may be on your plan’s website.  You then will need to file what is usually called a “request for reconsideration.” Depending on what the denial was for, this usually needs to be done either within 30 or 60 days of the date the denial was issued. You, your doctor, or other representative must ask for an appeal from your plan within 60 days of the date of the coverage determination. If you miss the deadline, you need to explain why you are late.

Find out specifically why the claim was denied. It is possible that there is just some missing information in the claims paperwork. When this happens, the claim can be corrected and resubmitted quickly.

What You’ll Need

Your appeal must include certain information:

  • Your name, address, and the Medicare number on your Medicare card.
  • The items or services for which you’re requesting a reconsideration, the dates of service, and the reason(s) why you’re appealing.
  • The name of your representative and proof of representation, if you’ve appointed a representative.
  • Any other information that may help your case.

It is standard to wait 30 days for a decision on your appeal. If you or your doctor think the delay in care could seriously harm you or put your life in jeopardy, you can ask for an “expedited” decision. The plan then must respond in 72 hours.

If the treatment doesn’t meet the plan’s general requirements for coverage, the plan may approve a peer-to-peer conversation between your physician and the plan’s medical director. This may settle the situation if your physician can show that that the originally requested treatment or service is medically necessary and/or essential to protect your safety and wellbeing.

Filing an appeal can be confusing and a bit overwhelming, but you don’t have to do this on your own. Your physician or skilled nursing center can help you or refer you to another professional such as a social worker or case manager who can help guide the process.

If At First You Don’t Succeed…

If your first appeal isn’t successful, there is a second appeals level. This usually involves an independent review organization that will take all the information and decide whether or not the denial should be upheld. As a last resort, you can take your case to an administrative law judge.

Be Your Own Best Advocate

It is important to be an informed consumer. Know what your plan covers, particularly regarding any health issues your current have as well as those you may be at high risk for. You can learn more on the medicare.gov website. If you have a complaint, concern, or question, you can call 1-800-MEDICARE.

“Policymakers want to know how Medicare beneficiaries like their plans and what problems or issues they may be having,” said Nisha Hammel, vice president of reimbursement policy and population health at the American Health Care Association/National Center for Assisted Living.  “There are organizations such as ours that are always seeking ways to improve care for our nation’s older population and helping to ensure that needed services and treatments are covered appropriately,” she stressed.